摘要
目的分析整改追踪责任制在提高医院病案书写质量的效果。方法质控科将病案质控过程中发现的共性问题,记录并发送《持续改进通知单》至科室负责人处,要求科室组织讨论、分析,制定切实有效的整改措施,再由质控科工作人员限期追踪改进情况。经过一段时间运行,观察某院病案质量的改善情况。结果 2018年持续改进通知单反馈率为89. 47%、落实率为84. 21%,分别较2017年同期提升46. 96%、65. 08%,病案缺陷率由2017年23. 67%降低至9. 77%,核心制度记录缺陷率由2017年的27. 76%降低至13. 62%,差异均有统计学意义(P <0. 05)。结论整改追踪责任制能够有效提高科室对病案质控存在共性问题的重视程度,降低共性问题发生率,提高整体病案质量。
Objective Analysis of the effect of rectifying and reforming the responsibility-tracking system in improving the quality of medical record writing in a hospital. Methods The quality control department records and sends the Notice of Continuous Improvement to the Department responsible for the common problems found in the process of medical record quality control,requests the Department to discuss and analyze,and formulate effective corrective measures,and then tracks the improvement by the staff of the quality control department within a time limit. Results In 2018,the feedback rate of continuous improvement notice was 89. 47% and the implementation rate was 84. 21%. Compared with the same period in2017,the feedback rate of continuous improvement notice was up by 46. 96% and 65. 08%,respectively. The Grade A medical record rate increased from 98. 65% in 2017 to 99. 23% in 2018,and the defect rate of medical record decreased from23. 67% in 2017 to 9. 77%. The difference was statistically significant( P < 0. 05). Conclusion Reforming the responsibility-tracking system can effectively improve the department’s attention to the common problems existing in the quality control of medical records,reduce the incidence of common problems,and improve the overall quality of medical records.
作者
尹璇
萧兵容
YIN Xuan;XIAO Bingrong(Department of Quality Control,Huizhou Third People’s Hospital,Huizhou 516000,China)
出处
《现代医院》
2020年第1期87-89,92,共4页
Modern Hospitals
关键词
持续改进
反馈追踪
病案
质量控制
Continuous Improvement
Feedback Tracking
Medical Record
Quality Control
