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目的通过评价设立质量控制人员前后的干预效果,探讨数字化病案质量的有效干预措施。方法对翻拍病案图片的错误进行归类并进行描述分析,并对翻拍人员进行质控干预,分别对干预前后的2016年7月1日-2016年7月8日和2016年7月9日-2016年7月15日的出院病案翻拍图片进行查阅,采用卡方检验对干预前后病案翻拍质量的问题发生率进行差异性分析。结果翻拍图片主要存在的问题是分类错误(67.62%)、重复错误(17.21%)、旋转错误(3.69%)、顺序错误(9.84%)、缺页错误(1.64%),干预前的问题发生率为8.30%,干预后的问题发生率为4.65%,干预后的问题发生率有所下降,干预具有一定效果。结论定期进行质控干预,分类错误重点审阅,激励发现问题并汇报,对关键环节保证信息准确性和完整性,从而使数字化病案得到更好应用,充分体现其价值。
Objective To evaluate the effectiveness of interventions before and after the establishment of quality control personnel to explore effective interventions for digitalized medical record quality. Methods To classify and describe the errors of the remake of the medical record pictures and to make quality control interventions on the remake personnel, respectively, before and after July 1, 2016 - July 8, 2016 and July 9, 2016 - July 15, 2016 remake pictures of discharged patients were reviewed, the use of chi-square test before and after the intervention case of the remake of the quality of the incidence of the problem were analyzed. Results The main problems in the remake pictures were categorization error (67.62%), repeat error (17.21%), rotation error (3.69%), sequence error (9.84%), missing page error Was 8.30%. The incidence of the problems after the intervention was 4.65%, the incidence of the problems after the intervention declined, and the intervention had certain effects. Conclusions Regular quality control interventions, misdirected reviews focus on problems identified and reported, and ensure the accuracy and completeness of the information for key links so that digital medical records can be better applied and fully reflect their value.