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[目的]探讨全程环节质量监控在病案质量控制中的作用。[方法]对2009年以来我院提交的所有病案予以质量监控,对比2009年与2010年的病案质量。[结果]随机抽取2009年病案2769份,缺陷病案115份,缺陷率4.15%;2010年病案3125份,缺陷病案29份,缺陷率0.93%;2010年病案缺陷率显著低于2009年病案缺陷率,二者之间比较差异有统计学意义(P﹤0.05)。[结论]病案环节质量监控对于确保病案质量有着十分重要的意义,值得借鉴应用。
[Objective] To explore the effect of whole process quality control in medical record quality control. [Methods] To monitor the quality of all medical records submitted by our hospital since 2009, compare the quality of medical records in 2009 and 2010. [Results] There were 2769 cases of medical records in 2009, 115 cases of defective medical records and 4.15% of medical records. 3125 medical records in 2010, 29 medical records of defective medical records and 0.93% of medical records were recorded. The medical records of medical records in 2010 were significantly lower than the medical records in 2009 , The difference between the two was statistically significant (P <0.05). [Conclusion] The quality control of medical records has very important significance for ensuring the quality of medical records, and is worth learning from.