行政与学术查房对病历书写及时性的干预作用

Intervention Function of Administrative and Academic Wards Round on Timely Writing Medical Record

目的探索病历管理中的行政与学术联合查房的干预作用。方法以行政查房和行政学术联合查房为处理因素,以各处理因素前后节假日新入院病历为研究对象,以病历书写及时性为观察指标,计数资料采用X2检验统计处理,规定P<0.05有显著差异。结果共计纳入267份病历,行政查房前组71份,行政查房后组62份,联合查房前组62份,联合查房后组72份。多组间比较X2值55.00,P<0.005。行政查房前后比较,X2值19.48,P<0.005。行政学术联合查房前后比较,X2值1.88,P>0.05。结论行政和学术权威因素的干预都有提升病历书写及时性的作用,在病案管理中侧重点有别。

Objective To study the function of administrative and academic wards round on the medical record management. Methods Administrative wards round and joint wards round of administrative and academic were fixed factors. New inpatient medical records before and after the fixed factors were taken as research objects. Chi -square test was used to compare the timeliness of writing medical records. Results 267 medical records were involved, including the 71 records before the administration, 62 records after the administration, 62 records before the administration jointed academic authority and 72 records after the administration jointed academic wards round. Timeliness for records writing is analyzed by Chi - square （ X^2 = 55.00, P 〈 0. 005=. The groups before and after the administrative joint measures, timeliness for records is analyzed by Chi - square （ X^2 = 1.88, P 〉 0. 05 ）. Conclusions Joint wards round of Administrative and academic has timely ascension action for medical records. The ascension action of administrative and academic authority in the medical records management is different.