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目的完善病案质量控制体系,充分发挥群众的力量,提高病案质量,达到医院评审的要求,保障医疗安全。方法运用临床科室出院病案自评系统,对出院病案实施科级质控,持续改进病案质量。结果自2015年6月使用出院病案自评系统后,质控出院病案评分率由原来的10%提高到70%,甲级病案率有原来的85%提升到98%。结论出院病案质量自评系统的使用,使得参与质控的病案数量、比例和范围均有显著提高,消除丙级病案,出院病案的完整性、准确性、及时性明显提高,且呈现持续改进态势,为后续的医疗、病案复制等活动奠定坚实的基础。
Objective To improve the medical record quality control system, give full play to the power of the masses, improve the medical record quality, meet the requirements of the hospital review and ensure the medical safety. Methods Using the self-assessment system of discharge department in clinical departments, the quality control of department discharges was implemented and the quality of medical records was continuously improved. Results Since the use of the Discharge Medical Self-Assessment System in June 2015, the score of quality-controlled discharge has been raised from 10% to 70%. The Grade A medical record has been upgraded from 85% to 98%. Conclusions The use of self-assessment system of discharge medical record quality makes the number, proportion and scope of medical records involved in quality control significantly improved. The completeness, accuracy and timeliness of discharge medical record are obviously improved and the situation of continuous improvement is eliminated , Laying a solid foundation for subsequent medical and medical record-keeping activities.