手术科室病案书写质量改进管理效果研究

Effect Research on the Quality Improvement Management of Medical Records Writing in Operation Departments

目的研究医院手术科室病案书写质量改进措施的应用效果。方法选择2014年第一季度出院病例数量≥180例的手术科室,对所选的8个手术科室的病案缺陷问题进行分析。跟踪监控2014年第二季度至2015年第二季度所选的8个手术科室的病案缺陷率,采用卡方检验对实施改进措施后病案缺陷率的变化进行分析。结果通过参加手术科室早晨交接班和借助互联网进行信息反馈,对手术科室和部分医师进行个性化培训以及制定全院和科室的奖惩制度等措施,病案缺陷率由2014年第一季度的20.9%下降至第二季度的13.9%,随后略有上升,在2015年第二季度达到最低值12.4%。经卡方检验,差异均有统计学意义(P<0.05)。结论医院医疗质量管理部门应结合手术科室的医疗工作模式特点,有针对性地为科室制定简单有效的改进措施,不断提高手术科室的病案质量,以保障医疗安全。

Objectives To study the application effects of medical records writing quality improvement measures in operation departments of a hospital. Method To conduct analysis on the defects existing in the medical records of eight operation departments which had more than 180 discharged patients in the first quarter of 2014. To monitor the rate of the defect rate in medical records of the eight operation departments from the second quarter of 2014 to the second quarter of 2015. Chi-square test was adopted to analyze the changes in the rate of disfigurement in medical records after the implementation of improvement measures. Results After the following implementation of improvement measures, information feedback by such as taking part in the morning shift of operation departments, strengthening the the Internet, organizing training in the departments and some of the doctors, as well as establishing the reward and punishment mechanism of hospitals and departments, the rate of defect rate in medical records was dropped from 20. 9% in the first quarter of 2014 to 13.9% in the second quarter, then rose slightly, and then in the second quarter of 2015 to achieve a minimum of 12. 4%. Chi-square test showed a statistically significant difference （P〈0. 05）. Conclusions The medical quality management department should put forward simple and effective improvement measures suited for each of the department according to the characteristics of medical work mode of operation departments, so as to improve the quality of medical record of operation departments continuously as well as ensure the safety of medical treatment.