终末病案专项质量控制对比分析

Comparative analysis on special quality control of archival medical record

目的分析终末病案存在的缺陷原原因,制定整改措施,提高病案质量。方法 2015年第一季度开始对归档甲级病案存在的问题,以"缺陷病历修改通知书"的形式告知主管医师并修改。随机抽取第一、二季度归档甲级病案各800份,比较首页及病历存在缺陷(包括15项内容)各项出现比例。结果第二季度缺陷内容发生率均明显降低。结论实施"病案缺陷修改通知书"专项整改后,终末病案质量明显提高。

Objective Analyzing the imperfection and the reason of terminal medical record, formulate rectification measures to improve the quality of medical record. Methods The problems were informed and modified to the competent physicians in the first quarter of 2015 archive class a medical records, with the form of＂notice of defect records modified＂. 800 copies of medical records were randomly extracted, the first and second quarter of grade a archiving, compared the results of home page and hospital medical records （including item 15）. Results quarter. Conclusion Archival medical record quality has improved significantly, records modified＂ The incidence of detect contents were significantly lower in the second after the implementation of special rectification with ＂notice of defect ＂