应用住院病历质量评价用表的效果评价

The Effect Evaluation on the Application of Quality Evaluation Table for Medical Records

目的应用新的住院病历质量评价标准,以促进病历质量的提高,并分析新标准的应用效果。方法 2012年3月-2013年2月,应用《住院病历质量评价用表》对终末病历进行检查。结果 4796份终末病历甲级率91.14%,单项否决率6.82%,单项否决主要原因是"病历中记录内容互相矛盾"及"会诊未在发出申请后48小时内完成"。结论新的评价标准在提高病历质量、防范医疗风险等方面起到了积极作用,同时也需在应用中不断完善。

Objective To promote the improvment of the quality of medical records and evaluate the effect of the new standards by applying new evaluation standard of the quality of medical record. Methods Evaluating the terminal medical records quality with the application of ＂Quality Evaluation table for Hospitalized Medical Records＂ during March 2012 to February 2013. Results Among 4796 medical records, 91.14% reached the first grade and 6.82% failed due to line-item veto. The most remarkable reasons for line- item veto were conflict recording in the medical records and consultation not finished within 48 hours. Conclusions The new evalua- tion standards play an positive role in the improvement of medical record quality and avoid the medical risk, and also need to be im- proved continuously in practice.