摘要
目的分析医联体成立前后乡镇卫生院住院病案质量,剖析书写缺陷问题及原因,提出改进对策以提高病案内涵质量。方法随机抽取医联体框架内的32家乡镇卫生院2015年-2016年和2017年-2018年共计12800份住院病案,统计分析医联体成立前后病历书写质量的缺陷。结果医联体成立前后缺陷率分别表现为病案首页由44.91%降低至34.86%、出院记录由39.63%降至30.94%、入院记录由32.92%降至25.84%、病程记录由48.89%降至32.23%,缺陷率显著下降,P<0.05,差异具有统计学意义。结论医联体建设可有效提高临床医师病历书写质量,通过强化质量意识和责任心、加强环节质量管理、完善奖惩机制等措施,切实提高乡镇卫生院的病案质量。
Objective Analyzing the medical record quality of township hospital before and after establishment of medical alliance and exploring the writing defects problems and taking corresponding measures to improve quality of medical record.Methods Medical record quality defect of 32 township hospitals was analyzed before and after medical alliance establishment,a total of 12800 medical records were randomly selected from 2016 to 2018.Results The writing quality developed inversely after medical alliance establishment,the rate of quality defects was as follows that defect rate of front page reduced from 44.91% to 34.86%,discharge record from 39.63% to 30.94%,admitting record from 32.92% to 25.84%,progress record from 48.89% to 32.23%.The defect rate declined obviously with significant difference.Conclusion The construction of medical alliance could improve writing quality efficiently.We should strengthen quality responsibility awareness and quality management,perfect the reward and punishment mechanism to improve the medical record quality of township hospital.
作者
王姝
曹爽
王芳
谷月
高树鹏
Wang Shu;Cao Shuang;Wang Fang;Gu Yue;Gao Shupeng(Fourth Affiliated Hospital of China Medical University,Shenyang 110032,Liaoning Province,China)
出处
《中国病案》
2019年第10期23-26,共4页
Chinese Medical Record
关键词
医联体
乡镇卫生院
住院病案
缺陷分析
Medical alliance
Township hospital
Medical record
Defect analysis
