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目的剖析目前运行病历质检的缺陷,探讨提高运行病历的完成质量的持续改进的措施,以促进医疗质量的全面提升。方法分别于2012年及2013年抽取外科电子病历及内科电子病历,统计缺陷病历的情况应用SPSS15.0统计软件进行分析,采用t检验处理和统计。结果外科组、内科组改进后缺陷份数百分比明显下降,有显著差异且有统计学意义(P<0.01);改进后百分比平均值均明显低于改进前,有显著差异且有统计学意义(P<0.01)。改进后的2013年病历质检的平均分明显高于同期2012年病历质检的平均分。从而促进甲级病案率的提升及医疗纠纷数明显下降。结论完善电子病历环节质控系统及信息化管理,加强持续改进,使运行病历质量不断提升,不仅有效降低医疗风险,也是全面提升医疗内涵质量的一个重要的环节。
OBJECTIVE To analyze the current defects of running medical records and to explore ways to improve the quality of finished medical records in order to promote the overall improvement of medical quality. Methods The surgical electronic medical records and medical electronic medical records and statistical medical records were analyzed by SPSS15.0 statistical software in 2012 and 2013 respectively. The data were analyzed by t-test and statistics. Results The percentages of defects in the surgical group and the medical group decreased significantly after the improvement, with significant difference (P <0.01); the average percentage after improvement was significantly lower than that before the improvement, with significant difference (P <0.01) P <0.01). The average score of the improved medical records in 2013 was significantly higher than the average of the 2012 medical records in the same period. As a result, the number of Grade A cases and the number of medical disputes have been significantly reduced. Conclusion Improving the quality control system and information management of EHR links and enhancing continuous improvement will continuously improve the quality of running medical records. This will not only effectively reduce the medical risks but also improve the quality of medical services in an all-round way.