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目的研究追踪方法学在病案管理工作持续质量改进中的应用效果。方法于2015年1月组建病案追踪方法学工作小组,对病案管理工作流程各个环节进行追踪管理,从系统上查找流程中的缺陷和不足,经过评估和分析,提出整改措施,加以改进和优化,达到完善工作制度、优化流程、提高工作质量的效果。结果出院病案72小时回收率由应用追踪方法学前的83.62%提高到92.18%;病案复印满意度由应用前的93.55%提高到98.19%;ICD编码准确率由应用前的91.06%提高到98.12%;病案首页缺陷率由应用前的26.64%降低至9.57%。结论通过应用追踪方法学,能够有效改进病案管理工作,从而促进病案管理工作质量持续提高。
Objective To study the application effect of tracking methodology in continuous quality improvement of case management. Methods In January 2015, a working group on the methodology of medical record tracking was established to track and manage all aspects of the medical record management workflow. The defects and shortcomings in the process were searched from the system. After the assessment and analysis, corrective measures were proposed and improved, Achieve the perfect working system, optimize the process, improve the quality of work results. Results The recovery rate of 72 hours after discharge was increased from 83.62% before application to 92.18% before the application. The satisfaction rate of medical records was increased from 93.55% to 98.19% before application. The accuracy of ICD coding was increased from 91.06% before application to 98.12%. The defect rate of the first page of medical records was reduced from 26.64% before application to 9.57%. Conclusion Through the application of tracking methodologies, medical records management can be effectively improved, and the quality of medical records management can be continuously improved.