住院医师质控科轮训在病历质控中的作用

Significance of resident physicians training in medical quality control department to medical record quality

目的:探讨临床住院医师在质控科轮训对医院整体病历质量的影响。方法:回顾性分析2006年前后4年中我院住院医师在质控科规范培训3个月后所书写的终末病历与未在质控科培训的住院医师所书写终末病历医疗缺陷5级构成情况[1],比较两组构成差异;随机抽取29名3～5年年资的住院医师,分为轮训组与未轮训组,在回顾性分析两组住院医师终末病历五级构成。结果:两组4年中书写终末病历医疗缺陷Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ5级构成情况比较显示有显著统计学差异P<0.01),轮训组Ⅰ、Ⅱ病历93.23%明显高于未轮训组89.22%;同期运行病历抽查显示,轮训后病历缺陷率较轮训前明显下降(64.49%与68.99%,P<0.01)。结论:临床住院医师质控科3个月轮训制度有利于医院病历质量的整体提高,值得各级医院借鉴和推广。

Objective To investigate the significance of the resident physicians training in medical quality control department to medical record quality.Method To analyze retrospectively the five grades medical record constituent ratios for the former four years before in 2005 non-triaining for medical quality control and that of the later four years after in 2005 the training for 3 months in our hospital,and compared their constituent ratios;29 resident physicians were drawed-off randomly who have 3~5 years past service,divided into two groups,one is the group of training and another is the group of non-trianing,to compare the difference of the five grades medical record constituent ratios between the two groups.Results There are a significant statistic difference forⅠ,Ⅱ,Ⅲ,Ⅳ and Ⅴ five grades medical record constituent ratios between the former and the later four years（P〈0.01）.ⅠandⅡgrades medical record have higher ratios in the later than the former（93.23.% VS 89.22%）,and the deficiency ratio of component element medical record is lower（64.49% VS 68.99,P〈0.01）.Conclusion The resident physicians′ training in medical quality control department for 3 months profits to improve the quality of medical record in a hospital,from small to big hospital,we can get benefits for medical quality control by this way.