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目的探讨病案室轮转制度对临床医师书写病案质量的影响。方法对比临床医师参加病案室轮转前后书写病历的质量,统计分析该制度实施前后的临床医师病案质量变化。具体方法是:所有新参加工作的临床医师,经统一组织、安排后,在病案复核室轮转工作至少3个月,主要工作是审核相关临床科室的出院病案,包括出院病案的质量、病案记录中涉及患者手术、有创操作等的签字,以及知情同意书的签字等病案法律法规等内容。同时,每位参与病案室轮转的医师还就《黑龙江省病历书写规范》进行理论学习。以理论指导病案室的病案审核工作,以实际工作加深轮转医师对病案质量、病案法律法规等相关内容的理解与掌握。结果临床医师参与病案室轮转前后病历书写规范合格率(81.7%VS.95.6%)、病案法律法规知晓率(79.7%VS.96.8%)、病案知识测验平均分(83.7±5.6 VS.95.2±3.7)、病案缺陷率(21.5%VS.9.7%)、重度病案缺陷率(12.3%VS.4.1%)、归档前病案返修率(13.7%VS.4.6%)、医疗纠纷涉及病案错误比率(66.7%VS.26.7%)等指标均有统计学意义。结论临床医师参与病案室轮转可显著改进其书写的病案质量。
Objective To explore the impact of medical records rotation system on the quality of written medical records by clinicians. Methods The quality of written medical records of clinicians before and after participating in the case rotation was compared with that of clinicians before and after the implementation of the system. The specific method is: all new clinicians, after unified organization, arrangement, rotation in the medical record review office at least 3 months, the main job is to review the relevant clinical departments discharge cases, including the quality of discharged medical records, medical records Involving patients with surgery, invasive operation of the signature, as well as the consent of the signature and other medical records laws and regulations and other content. At the same time, each physician who participated in the case-case rotation also conducted theoretical study on the “Medical Record Writing Standard in Heilongjiang Province.” To guide the examination of the case record of medical records in theory and to deepen the understanding and mastery of the contents of the record quality and medical record laws and regulations by the rotating physicians with practical work. Results The clinicians had 81.7% VS.95.6% medical records before and after their cases were rotated, the awareness rate of medical records laws and regulations (79.7% VS.96.8%), and the average scores of medical records knowledge test (83.7 ± 5.6 VS.95.2 ± 3.7 (21.5% VS.9.7%), severe case defect rate (12.3% VS.4.1%), pre-filing case rate (13.7% VS.4.6%), medical dispute cases involving case error rate (66.7% VS.26.7%) and other indicators were statistically significant. Conclusion Clinicians participating in the case rotation can significantly improve the quality of their written medical records.