摘要
目的观察病案管理前移控制模式前后住院病案质量的变化并分析意义。方法从2017年1月开始对住院病案管理实施病案管理前移控制模式,随机选取实施前2014年7月1日-2016年12月31日归档的20000份住院病案作为对照组,实施后2017年7月1日-2018年12月31日归档的20000份住院病案进行观察组;分析两组住院病案平均评分、病案缺陷程度、病案整改情况、病案等级情况以及病案质量缺陷项发生情况。结果病案管理前移实施后住院病案的病案平均评分(97.63±8.54)分、病案缺陷程度(3.21±0.44)、病案整改率(35.25±2.36)%均显著优于实施前指标水平,P<0.05;实施后外科与内科住院病案甲级率均显著高于实施前指标水平,P<0.05;实施后住院病案质量缺陷项情况有显著改善,P<0.05。结论实施病案管理前移控制模式对内外科住院病案质量的影响显著,提高医务人员工作效率,改善病案缺陷程度,有利于病案缺陷整改,提升病案书写质量,保障医疗质量与医疗安全,值得推广使用。
Objective Observe the change of the quality of hospital case management before and after the disease case management forward control mode and analyze the significance.Methods From January 2017 onwards,the implementation of the inpatient case management pre-shift control model,random selection 20.000 inpatient cases filed in December 2016 as a control group,after the implementation of July 2017 to December 2018 filed 20,000 inpatient cases to observe group,and then randomly selected before the implementation of July 2014.The average score of medical records,the degree of defects,the rectification of medical records,the grade of medical records and the occurrence of defects in the quality of medical records were observed.Results The average score of medical records(97.63±8.54) points,the defective degree of medical records(3.21±0.44) and the corrective rate of medical records(35.25±2.36)% after implementation were significantly better than those before implementation,P<0.05;After implementation,the grade A rates of surgical and internal medicine inpatient medical records were significantly higher than those before implementation,P<0.05;After implementation,the quality defects of inpatient medical records were significantly improved,P<0.05.Conclusion The implementation of the forward control mode of medical record management has a significant impact on the quality control of inpatient medical record in internal medicine and surgical,which can improve the work efficiency of medical staff,improve the defect degree of medical records is beneficial to the rectification of medical records,improve the quality of medical record,and ensure the quality and safety of medical treatment.
作者
郑奕
Zheng Yi(Department of Medical Record Management,The second Hospital of Tangshan,Tangshan 063000,Hebei Province,China)
出处
《中国病案》
2019年第10期26-28,共3页
Chinese Medical Record
关键词
病案管理前移控制模式
病案管理
病案质量
住院病案
Advance control model of medical record management
Medical record management
Medical record quality
Inpatient medical records
