疝与腹壁外科病案质量分析及持续改进策略

Quality analysis and continuous improvement strategy in medical record of hernia and abdominal wall surgery

目的通过对比分析疝与腹壁外科终末病案实施多环节质控前后结果,探究提高该科室终末病案书写质量的有效策略。方法分别抽取2013、2014年首都医科大学附属北京朝阳医院疝与腹壁外科环节质控前后终末病案进行缺陷分析,并采用SPSS13.0统计软件进行统计学比较。结果该科经多环节质控病案后,终末病案总缺陷率由20%下降至8%,各缺陷项目所占比例明显下降,医疗纠纷亦有所减少。结论加强疝与腹壁外科病案多环节质控,并综合采用培训、考核、抽查、监督、奖惩等方式对病案进行持续改进,可显著提高病案质量。

Objective A comparative analysis was conducted between before and after multi-link quality control applied in terminal medical records of hernia and abdominal surgery department,to investigate the effective strategy of improving quality of medical record in this department. Methods Terminal medical records of hernia and abdominal surgery department in Beijing Chao-Yang Hospital, Capital Medical University with or without multi-link quality control from 2013 to 2014 were collected and analyzed. The results were analyzed by SPSS13. 0 statistical software. Results After multi-link quality control,the total defect rate of terminal medical records from this department decreased from 20% to 8%. The proportion of each defect item was decreased obviously,while the medical disputes were also reduced. Conclusion Strengthening of the multi-link quality control in medical records of hernia and abdominal wall surgery department,and continuous improvement of medical record comprehensively using the measures of training,assessment,inspection,supervision,rewards and punishment,can significantly improve the quality of medical records.