[1]匡永利程小维陶晓钦李莹陶玥颖邓明德.临床医师病历质量管理认知调查与分析[J].中国卫生质量管理,2018,25(02):38-40.[doi:10.13912/j.cnki.chqm.2018.25.2.12]

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临床医师病历质量管理认知调查与分析

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第25卷期数: 2018年02期页码: 38-40 栏目: 医疗质量出版日期: 2018-03-28

作者:: 匡永利程小维陶晓钦李莹陶玥颖邓明德; 陆军军医大学第二附属医院

关键词:: 临床医师; 病历; 质量管理; 需求

Keywords:: Clinician; Medical Record; Quality Management; Requirement

DOI:: 10.13912/j.cnki.chqm.2018.25.2.12

摘要:: 目的了解临床医师的病历质量管理需求，以便针对性改进。方法在文献研究基础上，制定调查问卷，对医院150名临床医师进行调查，通过比率分析，了解临床医师对病历质量管理的需求。结果临床医师对病历书写规范和病历质量检查标准的培训需求较大；对病历基本规则培训需求较高；认为病历质量重点培训对象为进修生，重点反馈对象为经治医师，重点检查病历为死亡病历；希望多接受“走动式”培训；希望将纳入千分制考核等作为主要奖惩方式。结论临床医师病历质量管理可从丰富培训形式，拓宽反馈途径，建立三级质控屏障，完善考核标准等4方面着手，从而更好地保障病历书写质量，确保医疗质量与安全。

Abstract:: ObjectiveTo analyze the requirements of clinical physicians on the quality management of medical records, to provide reference for the innovative medical records quality control method, to adjust the quality and high efficiency quality control mode.MethodsBased on literature review, the questionnaire was designed for survey among 150 clinicians in hospital. The ratio analysis was used to investigate the requirements of the clinicians on quality management of medical records.ResultsThe training demand of the clinicians on the standard of medical record writing and the quality examination standard of medical records was great. The training demand for the basic rules of medical records was high. The main training subject was visiting students, the key feedback object was the attending doctors, and the main monitoring object was the death medical records. Clinicians hoped to accept the "walking" training, and to take into the assessment of thousand points system as reward and punishment measure.Conclusion The quality management of medical records among clinicians should take abundant training forms, broaden the feedback path, establish three-level quality control barriers, and improve the assessment standards, to better ensure the quality of clinicians writing medical records and to ensure the quality and safety of medical care.

参考文献/References:

［1］唐芳雪.某院医疗质量管理现状的调查与思考［J］.中国卫生质量管理，2009,16（4）：24-25.

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更新日期/Last Update: 2018-03-28