某院出院病历质量调查

Investigation on Quality of Discharged Medical Records in a Hospital

目的了解某医院出院病历质量现状,分析缺陷成因,探讨管理对策,为医院病历质量管理提供参考。方法2015年1—12月出院病历共96 842份,分层随机抽取15 086份进行质控,对质控结果进行汇总分析。结果甲级病案率为96.7%,病历质量总体处于优良水平。存在问题的病历占44.75%,手术科室缺陷率高于非手术科室。缺陷10 212项,缺陷项前三位分别为上级医师首次查房记录缺陷、首次病程记录缺陷、入院记录缺陷。结论落实病历质控制度化、常态化、精细化管理,是强化病历质量标准,进一步规范病历书写,提高病历内涵质量的有效措施;通过病历缺陷分析、讲评,强化主干医疗制度的落实,是促进医疗质量持续改进的有力抓手。

Objective To study the current situation of the quality of discharged medical records in a hospital,analyze the causes of defects,and put forward countermeasures so as to provide reference for the management of the quality of medical records. Methods A total of 15086 copies were selected by stratified sampling from 96842 discharged medical records from January to December in 2015 and the quality control results were summarized and analyzed. Results Grade A medical record rate was 96. 7%,and the quality of discharged medical records was at a high level on the whole. Problematic medical records accounted for 44. 75%. The record defect rate of surgical departments was higher than that of non-surgical departments. Among the 10212 lacking records found in the study,the top three were the defects of records when superior doctors made ward rounds for the first time,the record of first round of medical treatment as well as the record of hospital admission. Conclusion It is an effective measure to strengthen the quality control and improve the quality of medical records by implementing institutionalization and normalization of quality control and refining management. It is also a powerful means to continuously improve medical quality by analyzing defects and enhancing the implementation of main medical quality regime.