住院病案首页填写培训的效果评价

Effectiveness Evaluation of Training of Filling in the Front Pages of Inpatient Medical Records

目的分析住院病案首页填写时效和质量,发现目前存在问题,并针对问题提出改进方案。方法随机抽取某院3个试点科室妇产科、胸外科、感染与免疫科2019年10月1日-2019年12月31日1065份住院病案首页进行时效和质量监控,在2019年11月试行住院病案首页填写奖惩制度,并进行住院病案首页填写质量问题的第1轮培训,2019年12月进行第2轮培训,对比制度颁布前和第1轮培训的时效和质量,进行改进措施前后的效果评价。对住院病案首页填写及时率和合格率利用SPSS16进行统计学分析。结果制度颁布和质量培训双重措施干预前后比较,住院病案首页填写及时率为61.62%至80.98%(χ^2=31.35,P=0.000),合格率为61.89%至84.97%(χ^2=46.505,P=0.000);实施第2轮培训和第1轮培训的比较,住院病案首页填写及时率为80.98%至89.97%(χ^2=11.455,P=0.001),合格率为84.97%至90.78%(χ^2=5.567,P=0.012)。结论住院病案首页填写质量培训和制定奖惩制度措施同时进行能有效提高住院病案首页填写的时效与质量。为保障客观评价医院的各项绩效指标,进行第2轮培训比进行第1轮培训更有效。

Objectives To analyze the time limitation and quality of the front pages of inpatient medical records,and put forward the improvement plan.Methods 1065 copies of the medical records of the 3 pilot departments were selected randomly from October to December 2019,medical records were subjected to time-limited and quality control,and a system of rewards and punishments for filling out front pages of medical records was tried out in November 2019,the first training was conducted to fill in the quality problems on the front page of medical records,and the second round was conducted in December 2019 to compare the timeliness and quality of the training before and after the promulgation of the system,and to evaluate the effectiveness before and after the improvement measures.The front pages of medical records filling in the timely rate and the qualified rate were analyzed using SPSS16.Results Before and after the intervention,the rate of filling in the front pages of the medical record in time was 61.62%to 80.98%(χ^2=31.35,P=0.000),and the rate of passing was 61.89%to 84.97%(χ^2=46.505,P=0.000),the timely filling rate of the front pages of medical record was 80.98%to 89.97%(χ^2=11.455,P=0.001),and the qualified rate was 84.97%to 90.78%(χ^2=5.567,P=0.012).Conclusions Both the quality training and the establishment of reward and punishment system could effectively improve the timeliness and quality of the front pages of medical records.At the same time,to ensure the objective evaluation of the hospital’s performance indicators,two rounds of training was more effective than one round of training.