[1]安宇邓明杨娟林伟龙杨谨成杨文静.北京市31家医院乳腺癌化疗住院病历质控结果分析[J].中国卫生质量管理,2022,29(11):16-20.[doi:10.13912/j.cnki.chqm.2022.29.11.05 ]
　AN Yu,DENG Ming,YANG Juan.Analysis of Quality Control Results of Medical Records among Inpatients with Breast Cancer Chemotherapy in 31 Hospitals in Beijing[J].Chinese Health Quality Management,2022,29(11):16-20.[doi:10.13912/j.cnki.chqm.2022.29.11.05 ]

点击复制

北京市31家医院乳腺癌化疗住院病历质控结果分析

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第29卷期数: 2022年11期页码: 16-20 栏目: 特别关注出版日期: 2022-11-28

Title:: Analysis of Quality Control Results of Medical Records among Inpatients with Breast Cancer Chemotherapy in 31 Hospitals in Beijing

作者:: 安宇邓明杨娟林伟龙杨谨成杨文静; 国家癌症中心/国家肿瘤临床医学研究中心/中国医学科学院北京协和医学院肿瘤医院

Author(s):: AN Yu; DENG Ming; YANG Juan; National Cancer Center/National Cancer Clinical Research Center/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College

关键词:: 乳腺癌; 化疗; 住院病历; 单病种质量管理

Keywords:: Breast Cancer; Chemotherapy; Medical Records of Hospitalization; Single Disease Quality Management

分类号:: R737.9；R197.323

DOI:: 10.13912/j.cnki.chqm.2022.29.11.05

文献标志码:: A

摘要:: 目的了解北京市31家医院2020年乳腺癌化疗住院病历质控现状，并提出改进建议。方法以2020年北京市化疗质控检查中31家医院的106 份乳腺癌化疗住院病历为研究对象，应用SPSS 22.0软件进行数据统计，采用一般描述性分析、两独立样本t检验、配对样本t检验等方法进行数据分析。结果化疗过程质控亟待改善项目包括药物选择、剂量、用法记录以及化疗知情同意、化疗前常规检查、肿瘤分期，药事质控亟待改善项目为化疗方案确定及药物应用剂量是否有依据说明、药物输注时间是否合理。二三级医院比较，化疗病历质控评分总分、化疗过程质控评分、药事质控评分均不具有统计学意义（P＞0.05）；肿瘤内科化疗病历质控评分总分、化疗过程质控评分与非肿瘤科比较，差异均具有统计学意义（P＜0.05）。结论北京市医院乳腺癌规范化诊疗水平还存在较大改进空间。后续需以乳腺癌单病种质控工作为基础，制定乳腺癌单病种质控指标，规范病历书写，提高非肿瘤科医师乳腺癌化疗能力。

Abstract:: ObjectiveTo investigate the status of medical record quality control of breast cancer inpatients undergoing chemotherapy in 31 hospitals in Beijing in 2020, and to put forward suggestions for improvement.MethodsA total of 106 breast cancer chemotherapy inpatients from 31 hospitals in Beijing in 2020 were selected as the research object. SPSS 22.0 software was used for data statistics. General descriptive analysis, two independent sample t-test, paired sample t-test and other methods were used for data analysis.ResultsThe urgent improvement items in the process of chemotherapy included the records of drug selection, dosage, usage, informed consent for chemotherapy, routine detection before chemotherapy, tumor staging. The urgent improvement items in the quality control of drug were the determination of chemotherapy regimen, whether the dosage of drug was justified, and whether the time of drug infusion was reasonable. Compared with secondary and tertiary hospitals, the total score of quality control score of chemotherapy medical records, quality control score of chemotherapy process, and quality control score of pharmaceutical affairs were not statistically significant (P > 0.05). There were significant differences in the total score of quality control score of medical records of chemotherapy and the quality control score of chemotherapy process between medical oncology department and non-oncology department (P < 0.05).Conclusion There is still room for improvement in the standard diagnosis and treatment of breast cancer in medical institutions in Beijing. Based on the quality control work of single breast cancer disease, quality control indicators of single breast cancer disease should be formulated, medical records should be standardized, and chemotherapy ability of non-oncologists should be improved.

参考文献/References:

［1］SUNG H，FERLAY J，SIEGEL RL，et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries［J］.CA Cancer J Clin，2021，71（3）：209-249. ［2］季加孚.2020北京肿瘤登记年报［M］.北京：北京大学医学出版社，2021：146. ［3］邱亭林，杨培蔚，李国辉，等.北京市76家医院恶性肿瘤化疗质控现状调查研究［J］.中华肿瘤杂志，2018，40（4）：280-283. ［4］陈万青，荣寿.中国女性乳腺癌发病死亡和生存状况［J］.中国肿瘤临床，2015， 42（13）：668-674. ［5］曾慧慧，蒋荣猛，马旭东.我国单病种质量管理历史沿革及思考［J］.中国卫生质量管理，2021，28（10）：21-23. ［6］国家卫生健康委员会办公厅.关于进一步加强单病种质量管理与控制工作的通知：国卫办医函〔2020〕624号［EB/OL］.（2020-07-30）［2021-09-23］.http://www.nhc.gov.cn/yzygj/s7657/202007/b3175 5433b8e4a50b23906b9f1a07393.shtml. ［7］国家卫生健康委员会办公厅.2021年国家医疗质量安全改进目标［EB/OL］.（2021-02-09）［2021-09-23］.http://www.nhc.gov.cn/yzygj/s7657/202102/8c5 3313663284a7ba146648509538ee2.shtml. ［8］国家肿瘤质控中心乳腺癌专家委员会.中国乳腺癌规范诊疗质量控制指标（2022版）［J］.中华肿瘤杂志，2022，44（3）：203-208.�?倓［9］陈烨，王筱慧，钟海忠.某院肿瘤化疗病历现状与质量改进［J］.解放军医院管理杂志，2018，25（5）：423-425，443. ［10］张阳，陈妍，孙洲，等.医疗质量控制信息平台构建与应用［J］.中国卫生质量管理，2021，28（3）：56-57，61. ［11］蒋梦怡，陆言巧，王红霞.乳腺癌异质性的研究进展及临床意义［J］.中国癌症杂志，2020，30（5）：394-400.

相似文献/References:

[1]苏彩梅郭丝锦.乳腺癌日间手术全程健康管理模式探讨[J].中国卫生质量管理,2021,28(05):30.[doi:10.13912/j.cnki.chqm.2021.28.5.09 ]
　SU Caimei,GUO Sijin.Discussion on the Whole-Process Health Management Mode in Ambulatory Surgery for Breast Cancer[J].Chinese Health Quality Management,2021,28(11):30.[doi:10.13912/j.cnki.chqm.2021.28.5.09 ]
[2]管昀韩满霞补小康郑雪梅杜洪燕朱宁薛和玉吴绍勇.降低乳腺癌术后化疗患者中重度心理痛苦发生率[J].中国卫生质量管理,2022,29(05):80.[doi:10.13912/j.cnki.chqm.2022.29.5.20 ]
　GUAN Yun,HAN Manxia,BU Xiaokang.Reducing the Incidence of Moderate and Severe Psychological Distress in Breast Cancer Patients Undergoing Postoperative Chemotherapy[J].Chinese Health Quality Management,2022,29(11):80.[doi:10.13912/j.cnki.chqm.2022.29.5.20 ]
[3]赵将王雁郭萍利成改平张彧李宁刘小娜谢娟.陕西省护理人员化疗职业防护知信行调查[J].中国卫生质量管理,2022,29(06):45.[doi:10.13912/j.cnki.chqm.2022.29.6.12 ]
　ZHAO Jiang,WANG Yan,GUO Pingli.Investigation on Knowledge-Attitude-Practice of Occupational Protection Among Nurses in Chemotherapy in Shaanxi[J].Chinese Health Quality Management,2022,29(11):45.[doi:10.13912/j.cnki.chqm.2022.29.6.12 ]
[4]杨娟邓明杨谨成林伟龙时黎明安宇周成诚杨文静.北京市17家郊区医院恶性肿瘤服务能力及化疗质量现况调研[J].中国卫生质量管理,2022,29(11):25.[doi:10.13912/j.cnki.chqm.2022.29.11.07 ]
　YANG Juan,DENG Ming,YANG Jincheng.Investigation of Malignant Tumor Service Capacity and Chemotherapy Quality in 17 Suburban Hospitals in Beijing[J].Chinese Health Quality Management,2022,29(11):25.[doi:10.13912/j.cnki.chqm.2022.29.11.07 ]
[5]徐芸胡少华张海燕任春霞张秀梅张伟裴静梁琳.基于QFD构建乳腺癌术后化疗患者体重管理模式[J].中国卫生质量管理,2024,31(06):77.[doi:10.13912/j.cnki.chqm.2024.31.6.16]
　XU Yun,HU Shaohua,ZHANG Haiyan.Construction of Weight Management Mode for Breast Cancer Patients Undergoing Postoperative Chemotherapy Based on QFD[J].Chinese Health Quality Management,2024,31(11):77.[doi:10.13912/j.cnki.chqm.2024.31.6.16]
[6]郭丝锦黄美玲曹小花王廷.人工智能语音随访系统在乳腺癌日间手术患者随访中的应用分析[J].中国卫生质量管理,2024,31(10):24.[doi:10.13912/j.cnki.chqm.2024.31.10.06]
　GUO Sijin,HUANG Meiling,CAO Xiaohua.Application Analysis of Artificial Intelligence Voice Follow-up System in the Follow-up of Breast Cancer Patients undergoing Day Surgery[J].Chinese Health Quality Management,2024,31(11):24.[doi:10.13912/j.cnki.chqm.2024.31.10.06]
[7]汤丰榕段晓晓莫晓晨杜平丽韩许燕卢淑芳张蕾.应用QFD创新型品管圈构建乳腺癌患者癌性伤口治疗管理模式[J].中国卫生质量管理,2026,33(2):74.[doi:10.13912/j.cnki.chqm.2026.33.2.15]
　TANG Fengrong,DUAN Xiaoxiao,MO Xiaochen.Constructing a Treatment Management Model for Cancerous Wounds in Breast Cancer Patients Using the QFD Innovative Quality Control Circle Approach[J].Chinese Health Quality Management,2026,33(11):74.[doi:10.13912/j.cnki.chqm.2026.33.2.15]

更新日期/Last Update: 2022-11-28