病案质量监控成效分析

Analysis of effectiveness of medical record quality

目的:研究加强病历质量监控后病历质量改善情况及病历质量的提高对医院临床工作的影响。方法:通过对我院加强病案质检前(2006年1月至12月)随机抽查的350份病历及今年加强病案质控后1～2月份280份病历检查结果进行对比,比较加强病案质检前后错误发生率的变化。结果:通过我院加强对病例治疗的管理,我院病理质量有了明显的提高,机打病历的签字问题由28.6%降至22.3%,首页的自然项目填写齐全问题由11.8%降至10.7%,单项否决发生率由过去的9.4%降至3.4%,使因病历问题导致的纠纷及投诉比例由37.3%降至18.9%。结论:加强病案管理后,我院病历质量有了明显的提高,病历相关错误和病历相关的医疗纠纷明显减少(P<0.05)。

Objectives： To compare medical records quality when medical record regulation was emphasized and to find the relationship between medical record improving and medical quality promotion. Methods： 350 medical records before medical record regulation project （2006） and 280 medical records after the project were randomly selected. Mistakes rate in medical records were compared. Results： The mistake rate of copy dropped from 28.6% to 22.3%. The first page＇s mistake rate dropped from 11.8% to 10.7%. The rate of single reject mistake occurred dropped from 9.4% to 3.4%. Conclusions： Medical record quality was significantly improved and medical dispute related to medical record was significantly dropped （p〈0.05）.