病历质量控制体系运行情况分析

Analysis of Running Conditions of the Medical Record Quality Control System

目的分析病历质量控制体系运行情况,持续加强病历质量管理。方法回顾性分析2013年各项病历质量检查记录,分析病历质量控制体系运行存在的问题。结果病历质量控制体系运行情况良好,其中,1100份运行病历存在缺陷;检查并跟踪危重患者病案632份;检查死亡病历1406份,平均分85.64分;甲级病案抽查507份,甲级率89.74%;不合格输血病案89份,不合格率33.7%;恶性肿瘤化疗病案抽查134份,平均分89.7分,缺陷率72.4%;医保大额病案检查120份,不合格率67.2%。结论不断完善病案质量控制体系运行机制,运用信息化管理手段,提高病历质量控制能力和水平。

Objective To analysis the medical record quality control system and improve the quality of medical records management. Methods A retrospective analysis was taken to analyze the medical record quality inspection records of our hospital quality management organization in 2013 and the existing problems of this system. Results Medical record quality control system is running in good condition. A total of 1100 running medical record had defects; 632 critically ill patients were checked and tracked; The average score of 1406 death medical record was 85.64; Grade A rate of 507 medical record was 89.74%; Fraction defective of 89 blood transfusion records was 33.7%; The average score of 134 malignant tumor chemotherapy medical records was 89.7, defect rate was 72.4%; Fraction defective of 120 Large medical health care medical records was 67.2%. Conclusion We should constantly improve medical record quality control system, operation mechanism, improve the ability and level of medical records quality control through information management.