某院2016年前3季度病案首页手术操作相关信息质控情况的分析及对策

Quality control, analysis and countermeasure of the operation information on medical record home pages of a hospital in the first three quarters of 2016

目的调取某院2016年前3季度病案首页手术操作相关信息的填写情况进行质控,提高临床医师质量意识,规范医师填写行为,提高填报的质量。方法调取某院2016年前3季度有手术操作的病历首页进行质控和分析。结果质控病案首页手术操作相关信息24 740份,2619份医生填写存在缺陷,缺陷率为10.59%,缺陷条数有3435,缺陷每份强度为1.31,存在缺陷主要是手术切口愈合(41.08%)、手术级别(29.49%)、是否择期手术(13.48%)、漏填手术操作(9.61%)和手术选择有误(3.73%)。结论临床医师在首页手术操作相关信息填写质量方面存在一些缺陷,通过加强培训,提高医师质量意识,完善相关制度,研发首页质量监测与评估系统,引入激励机制,可促进填写质量。

Objective To collect the operation information on medical record home pages of a hospital in the first 3 quarters of 2016. To control the quality of those medical records. To improve the quality awareness of clinicians. To standardize the filling behavior. To improve the quality of filling. Methods The medical record home pages of a hospital in the first 3 quarters of 2016 were collected. The quality of those medical records and make analysis were controlled and analyzed. Results 24740 copies of medical record home page with operation information were analysed. 2619 doctors fill existed the defect, the defect rate was 10.59%. The number of defects was 3435, and the number of defects was about 1.31. The main defects were operative incision healing （41.08%）, operation level （29.49%）, elective surgery （13.48%）, missing filling operation （9.61%） and wrong operation （3.73%）. Conclusion There are some defects in filling the operation information on medical record home page for clinicians. The filling quality can be promoted by strengthening the training, improving the quality awareness of physicians, improving the relevant system, developing the quality monitoring and evaluation system of medical record home page and introducing incentive mechanism.