医疗质量实时监控系统对运行病历书写质量影响的研究

Research on the influence of medical record writing quality by implementing medical quality real-time monitoring and control system

目的:研究医疗质量实时监控系统是否可以提高运行病历的书写质量。方法:对实时监控前后共4年的运行病历书写质量进行回顾性分析,监控前共抽查960份运行病历,监控后检查24255份运行病历,从运行病历书写的及时性、完整性、内涵质量3个方面进行汇总分析。结果:监控前,运行病历书写的及时性、完整性、内涵质量的达标率分别为79.4%、94.9%、91.8%;监控后,3个指标的达标率分别为85.2%、98.2%、93.6%,病历书写及时性、完整性较监控前具有显著性差异(P<0.001),而病历书写内涵质量并无显著差异(P=0.114);监控后随时间变化,运行病历完整性达标率整体呈上升趋势,运行病历内涵质量达标率有轻度上升,运行病历及时性达标率先下降后上升。结论:医疗质量实时监控系统的应用是提高运行病历书写的及时性、完整性的有效方法,但对提高运行病历书写的内涵质量效果不明显。

Objectives： To study whether real-time monitoring system of medical quality can improve the writing quality of medical record. Methods： Retrospective analysis are made to compare the writing quality of medical records in four years before and after the real-time monitoring. 960 and 24255 medical records were randomly selected before and after implementing real time monitoring respectively. Timeliness, integrity and connotation of medical records were analyzed. Results： Before the monitoring, the respective up-to-standard rate of timeliness, completeness, connotation of medical record is 79.4%, 94.9% and 91.8%, and after monitoring, the respective up-to-standard rate of these three indicators is 85.2%, 98.2% and 93.6%. The timeliness and integrity of medical record shows a significant difference （ P〈0.001 ） , but connotation of the medical record writing （ P=O.114 ） has no significant change. After the monitoring, with time passing, the up-to-standard rate of integrity rises as a whole, the rate of connotation rises mildly, and the rate of timeliness rises first and then fails. Conclusions： Medical quality real-time monitoring and control system is an effective method to improve the timeliness and integrity of medical record writing but has no significant influence on connotation of the medical record writing.