病案质控分析与改进——以某二级医院为例

The Analysis and Improvement of Medical Record ——Take the Example of a Secondclass Hospital

目的:比较不同病案质量控制方法对病案质量的影响,为病案书写质控方法的选择提供科学依据。方法 :随机选取睢宁县人民医院心内科、普外科2014年1月~10月间实施终末病历质控351份和2014年11月-2015年9月间实施联合病历质控的病历资料403份,评价分析包括甲级病历率、病历缺陷率及主要病历缺陷在内的两组病历的质量变化。比较各种病案质量控制方法的效果。结果:实现联合质量控制在甲级病历率有明显提高,病历缺陷率出现了下降趋势,具有统计学意义(P<0.05)。结论 :联合质量控制可以更好的保障病案的质量。

Objective：Providing the scientific basis for the medical record writing through the different Qc methods comparing. Methods： Choosing the medical records of cardiology department and general surgery department of the People＇s Hospital of Suining County,the records which were the 351 terminal controled from January to October in 2014 and the 403 joint quality controled from November in 2014 to September in 2015, and compared the two control methods through the analysis about the a grade rates, defect rates and the main defection of the two groups of records above. Results：Through the joint quality control method, the a grade rates were obviously promoted,and the defect rates were declined,so it had the statistical significanc. Conclusion：The joint control method could gurarantee the quality of medical record.