摘要
目的探讨死亡病案的质量管理方法,为持续质量改进提供依据。方法以原卫生部《病历书写基本规范(2010版)》和《河北省医疗机构住院病历书写质量评估标准(2013版)》为标准,对2017年4月-2018年3月某院的死亡病案408份每月进行PDCA质量管理,再利用层别法、线性回归相关性分析、卡方检验方法对全部408份死亡病案质量缺陷数据进行统计分析。结果 408份死亡病案科室分布前3位的科室分别是重症医学科20.6%、肿瘤科20.1%、呼吸内科13.5%。其中病程记录缺陷72.3%、病案首页缺陷41.2%、书写基本要求缺陷25.7%、辅助检查缺陷18.6%、入院记录缺陷14.7%、死亡记录缺陷12.0%。死亡病案甲级率持续提高,具有统计学意义,P<0.01。非手术科室与手术科室病案甲级率比较,差异无统计学意义(P>0.05)。结论医院应重视死亡病案质量监控,通过质量分析、重点环节重要部位监控、PDCA等管理方法,持续提高死亡病案质量。
Objective To explore the methods of quality management of death medical records and provide evidence for continuous quality improvement. Methods To the ministry of health of the medical record writing basic specification（2010 edition）＂and＂ medical institutions in Hebei province was in the hospital medical record writing quality evaluation standards（2013 edition） ＂as the standard, in April 2017-the death of a hospital medical record in March, 2018, 408 per month for quality management, PDCA recycle layer method, the linear regression correlation analysis, chi-square test method to the data from all 408 death medical record quality defects were analyzed. Results among the 408 cases of death, the top 3 cases were 20.6% in the critical care department, 20.1% in the oncology department and 13.5% in the respiratory department. Including 72.3% defect of course record, 41.2% defect of first page of medical record, 25.7% defect of basic requirement writing, 18.6% defect of auxiliary examination,14.7% defect of admission record and 12.0% defect of death record.The first-grade death rate continued to increase with statistical significance, P〈0.01. There was no statistically significant difference（P〈0.05） in the first class rate of medical records between non-surgical department and surgical department. Conclusions hospitals should pay attention to the quality control of death medical records, and continuously improve the quality of death medical records through quality analysis, key links and important parts monitoring, PDCA and other management methods.
作者
韩旭
续红梅
何敬堂
叶文艳
辛成宝
魏猛响
Han Xu;Xu Hongmei;He Jingtang;Ye Wenyan;Xin Chengbao;Wei Mengxiang(China National Petroleum Corporation central Hospital,Langfang 065000,China)
出处
《中国病案》
2018年第11期8-10,共3页
Chinese Medical Record
关键词
死亡病案
病案质量
管理方法
持续改进
Death Cases Medical Records
Quality of medical records
Management methods
Continuous improvement
