摘要
目的分析终末质控病案缺陷分布情况及原因,为制定相应对策提供依据,提升病案质量。方法抽取海南省某三甲医院2019年1月1日至2022年7月31日出院患者病案26519份,组织专家依据检查标准开展终末病案质控工作,找出病案书写方面存在的问题。应用Excel归纳整理数据,采用SPSS20.0统计软件对数据进行分析与处理。定性资料用频数、率或构成比来描述,两组间率的比较采用卡方检验。结果本轮终末质控病案最高分99.5分,最低分80分,平均分94.48分。甲级病案26374份,占99.45%,乙级病案145份,占0.55%,无丙级病案。内科、外科乙级病案数量分别为64份、81份,乙级病案率分别为0.41%、0.74%。外科科室的乙级病案率高于内科科室(χ^(2)=12.624,P<0.001)。排在前三位的缺陷内容为:三级查房记录语言不简练、重点不突出、入院记录中现病史描述与主诉不符、日常病程记录中没有对患者病情及重要异常检查结果的分析及处理意见,频数分别为6078、3938、3913。结论该院病案质量整体已达到三级综合医院标准化建设关于甲级病案率≥90%、无丙级病案的要求,但病历书写仍存在较多缺陷,分布于住院病案首页、入院记录、首次病程记录、日常病程记录、三级查房记录、出院记录等各类项目中,外科科室缺陷多于内科。需采取相应措施,多管齐下改进病案质量。
Objectives To analyze the distribution and causes of defects in 26519 final quality control medical records,so as to provide a basis for formulating corresponding countermeasures and continuously improving the quality of medical records.Methods A total of 26519 medical records of patients admitted to a Three A and Tertiary Hospital in Hainan Province from January 1st,2019 to July 31st,2022 were selected,and experts were organized to carry out quality control of terminal medical records according to inspection standards to find out problems in writing medical records.Excel was used to summarize the data,and SPSS20.0 statistical software package was used to analyze and process the data.Qualitative data were described by frequency,rate or constituent ratio.Chi-square test was used to compare the rates between the two groups.Results The highest score of the final quality control record in this round was 99.50,the lowest score was 80.00 and the average score was 94.48.There were 26,374 Grade-A cases,accounting for 99.45%,145 Grade-B cases,accounting for 0.55%,and no Grade-C cases.The number of Grade B medical records in internal medicine and surgery was 64 and 81,respectively,and the rate of Grade B medical records was 0.41%and 0.74%,respectively.Surgical department Grade B medical record rate is higher than internal medicine department(χ^(2)=12.624,P<0.001).The top three defects were:the language of the third-level ward round records was not concise,the key points were not prominent;the description of present medical history in the admission records was inconsistent with the chief complaint;and there were no analysis and treatment suggestions on the patient's condition and important abnormal examination results in the daily course records,which were 6078,3938 and 3913 respectively.Conclusions On the whole,the quality of medical records meets the requirements of Grade A medical records rate≥90%and no Grade C medical records in the standardization construction of Three A and Tertiary General Hospitals.However,there
作者
韩丽珍
张京华
Han Lizhen;Zhang Jinghua(Hainan General Hospital(Hainan Affiliated Hospital Of Hainan Medical University),Haikou 570311,Hainan Province,China;不详)
出处
《中国病案》
2023年第10期13-14,100,共3页
Chinese Medical Record
关键词
病案质量
终末质控
缺陷
对策
Quality of medical records
Final quality control
Defects
Countermeasures
