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目的探讨全面质量管理在提高住院病历质量中的作用。方法对2011年23个临床科室的住院病历实施全面质量管理(干预组),抽样检查住院病历2820份,分析住院病历缺陷指数、缺陷整改率及平均住院病历评分值,并与2010年期间相应科室的2760份住院病历(基线组)进行比较,分析全面质量管理对于住院病历质量的影响。结果干预组住院病历缺陷指数明显低于基线组(分别5.3和3.4,P=0.000),住院病历缺陷整改率明显高于基线组(分别为36.0%和66.9%,P=0.000),平均住院病历评分值明显高于基线组(分别为94.8分和96.7分,P=0.000)。结论全面质量管理用于住院病历的质量管理,可明显提高住院病历质量。
Objective To explore the role of total quality management in improving the quality of in-patient medical records. Methods Total quality management (intervention group) of inpatient medical records in 23 clinical departments in 2011 was conducted. 2820 in-patient medical records were sampled and analyzed. The hospital medical record defect index, the defect rectification rate and the average hospitalization medical record score were analyzed and compared with the corresponding departments Of 2760 inpatient medical records (baseline group) were compared to analyze the impact of total quality management on the quality of hospitalized medical records. Results The inpatient medical record defect index in the intervention group was significantly lower than that in the baseline group (5.3 and 3.4 respectively, P = 0.000). The rectification rate of hospitalized medical records was significantly higher than that of the baseline group (36.0% and 66.9%, P = 0.000, respectively) The scores were significantly higher than those in the baseline group (94.8 and 96.7, respectively, P = 0.000). Conclusion Total quality management is used for the quality management of hospitalized medical records, which can obviously improve the quality of hospitalized medical records.