中医与中西医结合病案评价表的精细化及应用方法初探

Primary Investigation on the Refining and Application Method of Quality Evaluation Forms in Medical Records of Traditional Chinese Medicine and Combination of Chinese Traditional and Western Medicine

目的通过对中医与中西医结合病案评价表的精细化之前与之后相应时间段手术相关记录质量的改善说明使用精细化评价表的必要性;并介绍此精细化评价表全面应用的方法和作用。方法统计某中医院2015年1月-5月和2016年1月-5月住院病案检查登记表中安全核查表漏签名、手术相关记录的漏签名、手术相关记录漏打印、其他手术相关记录问题、首页手术操作项有缺陷、病程中的手术相关记录的有问题的病案数或问题数,期间所查手术病案为7764份,用卡方和t检验。结果使用精细化评价表后病案相关记录质量同期比较改善明显:手术安全核查表漏签名率由0.059降为0.027,卡方检验显示P<0.005;其他手术相关记录的签名问题由35.6±2.97降为24±1.58,t检验显示P<0.001;手术相关记录漏打印率由21.8±2.168降为12.6±2.302,t检验有明显改善;其他手术相关记录问题由33.8±2.39降为23±6,t检验有差异;首页手术操作缺陷率由0.068降为0.045,卡方检验显示P<0.005;病程中的手术相关记录问题亦有改善,卡方检验差异均为P<0.025。结论精细化的评价用表在提高病历质量、防范医疗风险等方面起到了积极作用,其全面完整应用的效果有待与同行进一步实践和评价。

Objectives To compare the quality of surgery related problems of medical records before and after the application of refining quality evaluation forms of Traditional Chinese Medicine Medical records,the quality of medical records had been significant improved,which showed it was necessary to apply refining evaluation table and introduced the method and function of the complete utilization of the table. Methods To collect frequency of occurrence of problems related with operation of a hospital of traditional Chinese medicine,which recorded in quality check form of medical records,7764 operation medical records have been checked of 1 to 5 months in 2015 and 2016. Statistical methods of Chir-square test and t test were adopted in the study. Results Related problems of medical record had significantly improved since the application of the refining evaluation table,signature problems of Operation Safety Check List had been improved from 0.059 to 0.027,Chir -square test had statistical significance with P〈0.005,signature problem of other surgery related records had been improved from 35.6±2.97 to 24± 1.58,t test had statistical significance with P〈0.001,forgetting printing problem of surgery related records had been improved,from 21.8±2.168 to 12.6±2.302,t test had statistical significance with P〈0.001,other problems of surgery related records had been improved from 33.8±2.39 to 23±6,t test had significance with P〈0.01. Problems of operation project of medical record homepage had been improved from 0.071 to 0.047,t test had significance, P〈0.005. Problems of surgery related records which existed in the course of disease record had been improved with Chir-square test had significance,and the statistical significance were all P〈0.025. Conclusions The refining evaluation table played a positive role on improving the quality of medical records and guard against medical risks,but the effect of its completely application still needed further practice and evaluate.