出院病历质量缺陷分析及持续改进

Quality Defects Analysis and Continuous Improvement of Terminal Medical Record

目的通过对出院病历质量缺陷进行分析,发现医疗质量存在问题,落实持续改进,提升医疗质量,确保患者安全。方法按10%以上的比例,对某院2012年度各住院科室出院病历进行抽查,对照相关标准审核评判,统计分析医疗质量缺陷。结果出院病历质量缺陷分析表明,全员质量意识不强,病历内涵质量有待提高,部分科室负责人责任意识不强等。对此,医院从坚持不懈抓意识教育、加强病历全程质控、落实奖惩等3方面进行了持续改进,提高了病历质量,提升了医疗质量水平。

Objective Through quality defect analysis on terminal medical records, the problems in quality of care can be found, and it benefits on the implementation of continuous improvement, and improves health care quality, ensures patient safety. Method Inpatient terminal medical record in different departments of the year 2012 were random checked according to 10% of the proportion in a hospital. The related standards were used for audit evaluation, statistical analysis was performed on medical quality defects. Result The quality of awareness was not strong, connotation quality of medical records needed to be improved, and some department heads had no strong sense of responsibility. In this regard, the hospital caught from persistent awareness education, strengthen quality control of medical records throughout the implementation of incentive and other three aspects of the continuous improvement. Implementation of measures improved the quality of medical records, and improved medical quality standards.