摘要
目的分析应用规范化病案管理对儿科病案质量的影响。方法选取2021年1月—2023年1月东莞市康复医院病案室在职的10名工作人员为研究对象,并抽取儿科病案200份为观察主体。根据管理方式不同,2021年1月—2022年1月实施常规病案管理为常规组,2022年2月—2023年1月实施规范化病案管理为规范组,每组对应选取100份儿科病案,两组为同一批工作人员。比较两组病案管理质量评分(书写及时性、书写质量、病案规范、病案真实)、工作人员对于病案管理模式的满意度。结果规范组书写及时性为(94.87±3.44)分、书写质量为(94.68±3.58)分、病案规范为(94.38±3.85)分、病案真实为(95.82±3.55)分,均高于常规组的(86.49±3.48)分、(85.64±3.78)分、(85.44±3.79)分、(85.39±3.84)分,差异有统计学意义(P均<0.05)。规范组工作人员的总满意度高于常规组。结论医院管理工作中,针对儿科病案应用规范化病案管理,应用效果理想,可显著提升儿科病案质量,提高工作人员满意度。
Objective To analyze the influence of standardized medical record management on the quality of pediatric medical records.Methods From January 2021 to January 2023,10 staff members in the medical record room of Dongguan Rehabilitation Hospital were selected as the research objects,and 200 pediatric medical records were selected as the observation subjects.According to different management methods,the implementation of routine medical record management from January 2021 to January 2022 was the routine group,and the implementation of standardized medical record management from February 2022 to January 2023 was the standardized group.Each group selected 100 pediatric medical records,and the two groups were the same staff.The quality scores of medical record management(writing timeliness,writing quality,medical record specification,medical record authenticity)and staff satisfaction with medical record management mode were compared between the two groups.Results The scores of timeliness of writing in the standardized group was 94.87±3.44, the writing quality was 94.68±3.58, the medical record specifica tion was 94.38±3.85, and the medical record was 95.82±3.55, which were higher than scores of those in the routine group 86.49±3.48, 85.64±3.78, 85.44±3.79, 85.39±3.84, and the differences were statistically significant (all P<0.05). The total satisfaction of the standardized group was higher than that of the routine group. Conclusion In the hospital management work, the application of standardized medical record management for pediatric medical records has an ideal application effect, which can significantly improve the quality of pediatric medical records and improve staff sat isfaction.
作者
辛俏芳
陈国
吴文英
李哲
辛俊英
XIN Qiaofang;CHEN Guo;WU Wenying;LI Zhe;XIN Junying(Medical Record Room,Dongguan Rehabilitation Hospital,Dongguan 523119,Guangdong,China;Department of Medical,Dongguan Rehabilitation Hospital,Dongguan 523119,Guangdong,China;Department of Child Development Behavior Center,Dongguan Rehabilitation Hospital,Dongguan 523119,Guangdong,China;Department of Children Rehabilitation,Dongguan Rehabilitation Hospital,Dongguan 523119,Guangdong,China;Department of Psychological Rehabilitation,Dongguan Rehabilitation Hospital,Dongguan 523119,Guangdong,China)
出处
《中国卫生产业》
2024年第11期28-31,共4页
China Health Industry
基金
2021年东莞市社会发展科技项目重点课题(20211800904832)
2023年东莞市社会发展科技项目重点课题(20231800940712)。
关键词
规范化病案
病案管理
常规管理
病案质量
Standardized medical records
Medical record management
Routine management
Quality of medical records
