《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]
卷:
第25卷
期数:
2018年05期
页码:
39-40
栏目:
医疗质量
出版日期:
2018-09-28
- 作者:
-
刘维 安书杰 张崇霏 肖妹 王宏斌 田妮娜 张珊红
-
空军军医大学西京医院
- 关键词:
-
病历质量; 精评病历; 专项检查
- Keywords:
-
Medical Record Quality; Fine Evaluation of Medical Records; Special Inspection
- DOI:
-
10.13912/j.cnki.chqm.2018.25.5.12
- 摘要:
-
目的 持续提升病历内涵质量。方法 设定病案首页填写、运行病历质控、终末病案质控、输血病历审核和培训整改5个指标，组织院级评价指导专家小组分批下科室进行病历质量精评专项检查，首次点评后的3个月、6个月、9个月再“回头看”。结果 经过初评和“回头看”抽取病历评价并进行前后比较，甲级病案率提升了26.67%，第2轮和第3轮“回头看”甲级病案率较第1轮均有统计学差异（P<0.05）。 结论 组织院内专家开展“精评病历”活动是提升病历质量的有效方法，操作性强，管理成本低，应继续坚持。
- Abstract:
-
ObjectiveTo continuously improve the contend quality of medical records. MethodsThe five indicators were set which included the standard of the front page of the medical record, the medical record process quality control, the final medical record quality control, the blood transfusion medical record review and the training rectification. The hospital-level evaluation and guidance experts team were organized to carry out the special inspection of medical record quality, with recheck after 3 months, 6 months, and 9 months.ResultsAfter the initial evaluation and recheck, the medical records were evaluated and compared, the percentage of first-grade medical records increased by 26.67%, and the percentage of first-grade medical records the second and third rounds of rechecks were statistically different from the results of the first round (P<0.05).Conclusion Organizing experts in the hospital to carry out the of medical records evaluation activities was an effective way to improve the quality of medical records with strong operability and low management cost, which should continue to be carried out.
参考文献/References:
［1］杨华娟，彭传薇，刘琛玺.后补医疗文书产生的原因［J］.解放军医院管理杂志,2017，24（3）：257-262.
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[1]张彦 阳红 陈兵 林敏 曹玲.信息化条件下病历质量监管流程改进[J].中国卫生质量管理,2016,23(06):10.[doi:10.13912/j.cnki.chqm.2016.23.6.04]
[2]王怡 白雪 崔胜男 任慧玲 张湛 刘振宇 范阳华 郭进京 冯铭.临床医学命名实体识别的病历质量筛选标准研究[J].中国卫生质量管理,2018,25(06):34.[doi:10.13912/j.cnki.chqm.2018.25.6.12]
[3]毛淋淇杨静徐婉瑛.基于院科两级质控管理体系的终末病历质量督查模式探讨[J].中国卫生质量管理,2021,28(09):32.[doi:10.13912/j.cnki.chqm.2021.28.9.09
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MAO Linqi,YANG Jing,XU Wanying.Quality Supervision Mode of Final Medical Records Based on Hospital and Department Quality Control Management System[J].Chinese Health Quality Management,2021,28(05):32.[doi:10.13912/j.cnki.chqm.2021.28.9.09
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更新日期/Last Update:
2018-09-28
