407份院级终末病案质量评价结果分析

Analysis on Quality Evaluation Results of 407 Copies of College Final Medical Record

目的：了解医院病案质量现状，探索提高病案质量的办法。方法选取山东省某二甲医院2014年2月～8月院级质控的407份终末病案评价结果，运用统计图表等展示该院病案质量水平，找出病案质量薄弱环节，改进病案质量。结果2014年2月～8月，该院甲级病案318份（78.13%）、非甲级病案89份（21.87%）；89份非甲级病案中手术系列科室69份（占77.53%），因单项否决因素导致的51份（占57.30%）等。病案质量整体没有明显改进效果，该院病案质控体系、培训等系统存在严重缺陷。但单项否决情形逐渐减少，病案质控工作取得阶段性成效，在提高病案质量的方法、途径方面有新的启发。结论建立健全院科两级病案质控体系，运用“品管圈”等质量管理工具，消除病案质量系统存在缺陷，按专题有序推进，提高病案质量。

Objective To understand the current situation of hospital medical record quality, explore the way to improve the quality of medical records. Methods Selecting 407 Terminal medical record evaluation results from February 2014 to August 2014 in grade-A hospital of second class in Shandong, and using statistical charts to show the hospital medical record quality level, find the weak link of the quality of medical records, improve quality of medical records. Results From February 2014 to August 2014, the grade A medical record 318 （78.13%）, Below grade A 89 （21.87%）;the operation Department 69 （77.53%）;51 copies of the line item veto factors leading to （57.30%） etc. The quality of the medical record overall has no obvious improvement effect, serious defects in the hospital medical record quality control system, training system. But the line item veto situation was gradually reduced. Medical record quality control work achieve substantive results, such as a new heuristic approach to methods can improve the quality of medical records. Conclusion To establish and perfect the hospital medical record quality control system of two levels, using the ring pipe products such as quality management tools, eliminate the defects of medical record quality system, according to the project to improve the quality of medical records.