实施运行病历质量监控对终末病案质量的影响分析

Analysis the effect on quality of terminal medical records by performing quality supervision for running medical records

目的我院自2006年起开始实施运行病历质量监控,通过比较2006年前后三年的终末病案质量指标,分析实施运行病历质量监控对终末病案质量的影响。方法随机抽取病案,专家分组,根据《中山大学住院运行病历评价标准》对环节病历进行评分,计算合格率,提取终末甲级病案率、病案回收率、病案缺陷率等统计数据,采用SPSS13.0统计软件进行分析。结果 2006年前后三年各科室的平均终末甲级病案率、病案缺陷率、病案回收率的差值有统计学意义;2006～2008年终末甲级病案率、病案回收率呈逐年递增曲线,并且与同期环节病历合格率递增趋势一致。结论实施运行病历质量监控对终末病案质量的提高有促进作用。

Objective Quality supervision for running medical records has been performed in our hospital since 2006.To analysis the effect of quality supervision on quality improvement of terminal medical records by comparing the quality index of terminal medical records in the 3 years before 2006 with that in the 3 years after 2006.Methods Picked out medical records randomly.Specialists were divided into deferent groups to give a mark for deferent parts of the medical records respectively according to the criterion for clinical record evaluation of Sun Yat-sen University.Calculated qualification rate,rate of terminal medical records in the first rank,retrieval rate and defect rate of medical records,all the date were analyzed with SPSS 13.0.Results The average rate of terminal medical records in the first rank of all clinical departments,defect rate and retrieval rate of medical records in the 3 years before 2006 were significantly deferent from those in the 3 years after 2006.Rate of terminal medical records in the first rank and retrieval rate of medical records increased every year form 2006 to 2008,coincident with the increasing qualification rate of component medical records in the same period.Conclusion Performance of quality supervision for running medical records was helpful to quality improvement of terminal medical records.