病案质量控制管理的方法与效果研究

Study on methods and effects of medical records quality control management

目的探求保持病历质量持久发展的质控管理方法。方法对照《广东省病历书写规范》,回顾性调查6年出院病历质控结果、质控管理上出现的问题、针对问题采取的措施、改进后的效果,总结提高病历质量的可行方法。结果病历质量整体呈上升趋势;质控后病历甲级率增高,丙级病历消除;病历质控管理实践中不断有管理困难出现;适时修正问题、持续改进工作方法能提高质历质量。结论健全质控组织体系、合理调整不适宜的评价指标体系、建立有效的反馈和交流机制、渗入人性化管理思潮是提高病历质量的有效途径。

Objective To investigate quality control management methods for maintaining lasting development of medical records. Method According to the Writing Criterion of Medical Record of Guangdong Province, we retrospectively analyzed the results of discharge medical records of last six years, the problems of quality control management and measures applied to resolve the problems as well as improved effects to summarize feasible meth- ods of improving medical records quality. Result Overall, medical records quality tended to improve; ratio of grade A medical records increased while grade C medical records were eliminated; difficulties occurred continuously in the practices of medical records quality control management; medical records quality can be efectively improved by correcting problems timely and improving working methods continuously. Conclusion Perfecting quality control organization system, adjusting inapplicable evaluation parameter system reasonably, establishing effective mechanism of feedback and communication and intermingling humanized management thought are effective ways to improve medical records quality.