心内科运行病历持续性改进策略和效果分析

Continuous Improvement Strategy and Effect Analysis of Running Medical Records of Cardiology Department

目的实践持续性改进策略,提高心内科运行病历质量。方法随机抽查2012年1月-3月400份运行病历为对照组,2012年7月-9月400份运行病历为观察组,综合采用培训、考核、抽查、监督、奖惩等方式,对运行病历质量持续性改进3个月,比较整改前后的运行病历质量。结果对照组与观察组单项否决病历份数分别为5份(1.3%)和1份(0.3%),甲级病历数分别为330份(82.5%)和385份(96.3%),乙级病历数分别为56份(14.0%)和12份(3.0%),丙级病历14份(3.5%)和3份(0.8%),差异均具有统计学意义(P均<0.01)。对照组与观察组病历平均分分别为(86.3±6.8)分和(95.9±3.1)分,差异具有统计学意义(P<0.01)。结论综合采用培训、考核、抽查、监督、奖惩等方式对心内科运行病历进行持续性改进,可显著提高病历质量。

Objective To practice continuous improvement strategies, and improve the cardiology medical record quality. Methods A total of 400 running records from January 2012 to march 2012 were randomly inspected as control group. A total of 400 running records from July 2012 to September 2012 were randomly inspected as the observation group. Some methods such as training, assessment, examination and supervision, rewards and punishments had been taken to improve medical record quality for 3 months. Comparing the quality of medicai records before and after improvement. Results The number of single veto medical records of control group and observation group were respectively 5 （1.3 % ） and 1 （0.3 % ）. The number of class A medical records were respectively 330 （82.5 % ） and 385 （96.3 % ）. The number of class B medical records were respectively 56 （ 14.0% ） and 12 （3.0%）. The number of class C medical records were respectively 14 （3.5%） and 3 copies （0.8%）. The differences are significant （P 〈 0.01）. Conclusion The methods of training, assessment, examination and supervision, rewards and punishments can significantly improve the quality of medical records.