1093份特勤疗养档案缺陷的分析与对策

Analysis and Countermeasure of Defects in 1093 Archived Special Service Recuperation Documents

目的 分析归档特勤疗案的缺陷,寻找相应的对策,持续改进与提高特勤疗案质量.方法 对2015年1月1日-2018年12月31日1093份归档特勤疗案,按照规范要求逐份进行质量检查,对缺陷问题进行分析总结.结果 1093份归档疗案均存在缺陷,其中疾病疗养记录缺陷1295项,占37.16%;疗程记录内容缺陷1094项,占31.39%;各种检查记录缺陷805项,占23.10%;2016年的疗案平均质量较2015年显著改善,平均每份疗案扣分值从4.38分降至2.76分,退改疗案由26份降至4份;2017年及2018年疗程记录内容不规范问题呈持续上升趋势,病史记录简单考贝问题在2018年跃升为第2位;采用卡方检验统计比较4年间甲级疗案数和退改数,差异显著.结论 特勤疗养作为一门新分支学科,疗案书写内涵与规范性方面存在明显不足,需要各级领导重视和全体医护人员参与,需要在特勤疗养人才队伍建设、硬件配套设施投入、建立系统性评价体系及完善相关制度性规定等方面持续改进.

Objectives To analyze the defects in the archived special service recuperation documents and think about countermeasures so as to improve the quality of special service recuperation documents continuously.Methods According to the requirements,we check the quality of 1093 archived special service recuperation documents one by one,then analyze and study the defects from January 1st,2015 to December 31,2018.Results Defects were found in all 1093 archived documents.Among them,1295(37.16%)defects in recuperation records,1094(31.39%)defects in the course records of treatment,805(23.10%)defects in various inspection records.The average quality of recuperation documents in 2016 was significantly improved compared with that in 2015,with the average deduction point per recuperation document falling from 4.38 points to 2.76 points,and the number of returned documents falling from 26 to 4.In 2017 and 2018,the problem of the irregular course records of treatment continued to rise,and the problem of simple cloning of medical history records jumped to the second place in 2018.SPSS statistical software was used to perform chi-square test on the number of grade A recuperation document and the number of returned documents in 4 years,showing a significant difference.Conclusions Special service recuperation was a new discipline.There were obvious deficiencies in the connotation and standardization of recuperation document writing,which requires leaders at all levels to attach importance to and all medical staff to participate,and continuous improvement in the construction of special service recuperation talent team,investment in hardware supporting facilities,establishment of systematic evaluation system and improvement of relevant institutional regulations.