住院病案质量评审系统的开发及应用

Development and Application of the Quality System of Hospitalizatton Medical Records

病案质量在一定程度上代表科室及医院的管理水平,作为医院等级评审工作中的重要组成部分。我们采取快速原型法开发“住院病案质量评审系统”,通过计算机输入储存、分析住院病案评审结果,“量化”了各级各类人员病案质量指标,并与责任者奖惩挂钩,加强了科室及医院管理,使我院病案质量显著提高,自1993年初至1994年二季度,全院住院病史甲级病案率由46.0％上升到94.8％,乙级病案率从52.4％下降到5.2％,消灭了丙级病案。

The quality of the medical records reflects. to some extent, the menagerial level of the department and hospital. It is also one of the important factors in assessment of the hospital level. Using rapid prototyping, we creat the Quality Evaluation System of Medical Records. According to this system, the result of medical record evaluation was input, stored and analysed, quantifying the quality standards of the madical records of all medical staff. The quantified quality standards played important parts in deciding prize and punishment. This has strengthened the management of the departments and the whole hospital, and the quality of the medical records has been obviously inereased. Since the beginning of 1993 to the second quarter of 1994, the upper class rate of medical record in our hospital is increased from 46. 0% to 94. 8%. The middle class rate is decreased from 52. 4% to 5. 2% and the lower class disppeared.