论文部分内容阅读
目的对2015年7月1日至2016年6月30日的1497份终末出院病案的书写质量进行统计分析,查找其缺陷问题,并提出相应解决方案。方法依据原卫生部颁布的《病历书写基本规范》及住院病案质量评价用表设计病案质控量表,对病案缺陷项目进行分类统计与分析。结果 1497份病案中有1494份存在不同程度的缺陷,缺陷率为99.80%。缺陷项数从1处到27处不等,其中3处及以上缺陷有1348份。问题病案比率最高的是临床技术类的中医技术占74.42%,其次是书写规范类的其他书写规范占62.66%,书写规范类的中医内容缺陷病案占52.97%,排第三位。结论病案质量控制是一个持续管理改进的过程,医院应适度改变中医整体观念思路,实施临床路径管理,实现病案质量控制流程化,引用先进的管理理念与方法,建立一套合理的、科学的,结合自身特点“量身定制”的质量管理体系。
Objective To statistically analyze the writing quality of 1497 final discharge cases from July 1, 2015 to June 30, 2016, find out the defects, and propose corresponding solutions. Methods According to the “Basic Rules for Writing Medical Records” promulgated by the former Ministry of Health and the quality control scales for inpatient medical record quality assessment, a statistical analysis and analysis were performed on the items of the medical record defect. Results There were 1494 defects in different degrees in 1497 cases, and the defect rate was 99.80%. The number of defect items ranges from 1 to 27, with 1348 defects in 3 or more defects. The highest proportion of problematic cases was in the category of clinical techniques, which accounted for 74.42% of the total TCM, followed by the other writing standards for the written specification category of 62.66%, and the TCM deficiency category of the writing specification category accounted for 52.97%, ranking third. Conclusion The quality control of medical records is a process of continuous management improvement. Hospitals should appropriately change the overall concept of Chinese medicine, implement clinical pathway management, realize the flow control of medical record quality control, and use advanced management concepts and methods to establish a set of reasonable and scientific methods. Combined with its own characteristics “tailored ” quality management system.