医院归档病历质量分析与对策

Quality analysis of archive medical records and countermeasures in our hospital

目的:对医院归档病历进行质量分析,针对存在的主要缺陷,提出适宜对策,以利于提高病案质量,防范医疗纠纷。方法:按10%的比例随机抽取2011年4月～2011年9月份归档病历1 415份,按照《广东省病历书写与管理规范》要求进行缺陷统计。结果:1 415份抽查病历中,甲级病历1 347份(95.19%),乙级病历68份(4.81%),无丙级病历,手术与非手术科之间甲级病案率差异无统计学意义(P>0.05)。缺陷统计总次数2 124次,是抽查病历的1.5倍。缺陷率位居前三位的项目分别为病程记录无内涵(21.63%)、入院记录中诊断缺陷(21.27%)和上级医师查房记录缺陷(15.34%)。结论:医院归档病历甲级病案率较高,但出现缺陷次数较多。今后应加大病案质控力度,及时发现问题及时反馈,减少病历缺陷次数,提高病案质量,避免医疗纠纷的发生。

Objective To analyze the quality of archive medical records of my hospital, and make appropriate countermeasures for major defects in order to improve the quality of medical records and prevent medical disputes. Method Total 1 415 medical records were randomly selected from archive medical records during April and September 2011 by 10% ,and counted defects in accordance with the ＂ Medical re- cords writing management standards of Guangdong Province＂. Results Of 1 415 copies of archive medical records, the numbers of class A and class B respectively were 1 347（95. 19% ） and 68 （4. 81% ） ,and there was no class C. There was no statistically significant between the rates of class A of sttrgieal and non - surgical departments （ P 〉 0, 05 ）. The total number of defect statistic was 1.5 times of sample re- cords. Defect rates among the top three items were recorded for the duration of non - content （21.63%） ,hospital record diagnosis of defects （21.27%） and higher physician rounds record defects （ 15. 34% ）. Conclusion The class A rate of the archive medical records is higher in our hospital, but defective number is more. We should enhance efforts to control the medical record, and detect timely of problem, feed- back timely in order to reduce the number of medical record defects, improve record quality and eliminate the occurrence of medical dis- putes.