摘要
目的 对某三级口腔医院口腔种植科病案开展质控,分析质控结果和造成缺陷的原因,提出对策,以提高病案质量。方法 调取某三级口腔医院2019年1月1日-2019年12月31日归档口腔种植科病案480份,按照《中华人民共和国侵权责任法》、《病历书写规范(第2版)》和《关于进一步加强医疗机构高值医用耗材临床应用管理的意见(苏卫医政[2019]24号)》结合口腔种植专科特点制定统一标准,对调取的病案开展质量检查。由病案管理委员会委派副主任医师以上职称医师开展质控。结果 480份病案中缺陷病案153份,缺陷率26.5%。总缺陷次数251次,其中口腔种植部分缺陷112次,占总缺陷数的44.6%;知情同意书部分缺陷11次,占总缺陷数的4.4%;口腔修复及复诊部分缺陷128次,占总缺陷数的51.0%。结论 口腔种植科病案各环节均存在不同程度的缺陷,需进一步提高医师法律和风险意识,建立病案长效管理机制,利用信息化、智能化监管手段开展质控,提高病案书写质量。
Objective In order to improve the quality of medical records,quality control was carried out in dental implantology department of a tertiary dental hospital,the quality control results and causes of defects were analyzed,and countermeasures were put forward.Methods A total of 480 medical records were collected from the department of dental Implantology in a tertiary dental hospital from January 1 st,2019 to December 31 st,2019.In accordance with the "tort liability law of the People’s Republic of China,the medical record writing standards(second edition)","the medical record writing standard(second edition)" and "on further strengthening medical institutions the opinions of the clinical application of high value medical consumables management(Su Wei medical administration [2019] no.24),combining with the characteristics of oral planting specialized formulate unified standards,to obtain the medical record to carry out quality inspection.The medical record management committee shall appoint physicians with titles above deputy chief physician to carry out quality control.Results Among 480 cases,153 cases were defective,the defect rate was 26.5%.The total number of defects was 251,including 112 partial defects of oral implants,accounting for 44.6% of the total number of defects.There were 11 partial defects in informed consent,accounting for 4.4% of the total defects.Oral repair and re-examination of partial defects 128 times,accounting for 51.0% of the total number of defects.Conclusions There were different degrees of defects in the medical records of the department of dental Implantology.It was necessary to further improve the legal and risk awareness of doctors,establish a long-term management mechanism of medical records,use information and intelligent supervision to carry out quality control,and improve the quality of medical records writing.
作者
周扬
陆晓欣
邵辰杰
邓润智
闫翔
于翠婷
Zhou Yang;Lu Xiaoxin;Shao Chenjie;Deng Runzhi;Yan Xiang;Yu Cuiting(Nanjing Stomatological Hospital,Medical School of Nanjing University,Nanjing 210008,Jiangsu Province,China;不详)
出处
《中国病案》
2022年第6期31-34,共4页
Chinese Medical Record
基金
江苏省医院协会医院管理创新研究课题(JSYGY-3-2019-110)。
关键词
口腔种植科
病案
质量分析
对策
Dental implant department
Medical records
Quality analysis
Countermeasures
