摘要
目的分析住院患者运行病历和终末病案中存在的缺陷,提出改进对策以加强病案质量管理。方法根据江苏省《病历书写规范》和《住院病历质量评定标准》,对抽取的江苏省某综合性三甲医院1482份运行病历和3610份终末病案进行系统评估,运行病历按照《住院病历质量评定标准》中列举缺陷计算缺陷率,终末病案按照《住院病历质量评定标准》进行评分以及缺陷率点评。通过科主任、临床医师、医院管理人员座谈会及关键人物半结构访谈进行原因及对策分析。结果终末病案中甲级病案4895份(96.13%),乙级病案197份(3.87%),无丙级病案;运行病历中有881例缺陷病历,缺陷发生率为59.44%,包括缺少阶段小结、科室大查房记录、未体现三级医师查房、病程记录不及时或空白等;终末病案中有2170例缺陷病案,缺陷发生率为60.11%,包括未体现三级查房、查房内容及病程记录过于简单等;缺陷原因分析中,住院和进修医师反应科室管理缺位和信息化建设方面原因比例均高于上级医师,差异具有统计学意义(P<0.05)。结论病案总体质量良好,但缺陷发生较多,主要原因在于科室管理缺位和医师专业素养不够,应通过法制教育和培训等措施加强质量控制,借助信息系统构建多系统整合的病案管理模式。
Objective To analyzerunning medical records and terminal medical records and identify existing defects, thus promotingstrategies for quality improvement. Methods Based on the ＂Medical Record Writing Standards in Jiangsu＂ and ＂Quality Standard of Inpatient Medical Records in Jiangsu＂, 1482 running medical records and 3610 terminal medical records were collected and systematically reviewed.Forum and semi-structured interviews on key stakeholders were organized to find the the causes of defects and promote the strategies.Results There are 4895 class-A medical records（96.13%）, 197 class-B medical records（3.87%）, no class-C medical records;And there were 881（59.44%） cases mistakes inrunningmedical records 2170（60.11%） cases in the terminal medical records, including the lack of stage summary, department records, course record writing delay and others. Moreover, there were significant difference between the two-level physicians as for opinions on the medical record defects（P0.05）. Conclusion The quality ofmedical records are overall good. However, there is still some defects because of absence of department management and professionalism of doctors. Besides, legal-related education and training, and multi-system should be integrated together for the quality control.
出处
《中国病案》
2017年第8期22-24,共3页
Chinese Medical Record
基金
国家档案局科技立项项目(2015-R-34)
关键词
病案缺陷
病案质量
三级质控
电子病历系统
Medical records defects
Medical records quality
Three-level quality control
EMRS
