病案管理前移的效果评价

Impact Assessment of Medical Record Management Forward Model

目的探讨病案管理前移模式在提高病案质量中的应用。方法随机抽取某三级甲等医院2015年(病案管理前移前)、2016年(病案管理前移后)1月-12月临床科室终末病案各2500份进行统计分析。结果实施病案管理前移后,病案7日归档率显著提高,内科由病案管理前移前的88.75%上升为99.75%,外科由病案管理前移前的85.29%上升为96.20%,差异有统计学意义;病案等级有明显改善,甲级病案由病案管理前移前68%提高至99%,乙级病案由30%降为0.87%,丙级病案由2%降为0.03%,外科甲级病案由病案管理前移前50.2%提高至64.2%,乙级病案由42.3%降为35.2%,丙级病案由7.5%降为0.6%,且有统计学差异。结论病案管理前移模式可以提高病案质量,减少医疗纠纷,提高病案7日归档率,可在医院内推广使用。

Objective To explore the application of medical record management forward model in improving the quality of medical records. Methods A total of 2500 medical records were collected from January to December in each of the tertiary hospitals in 2015（before the medical record management moved forward） and 2016（after the medical record management moved forward）. Results The rate of archival filing increased significantly from 88.75% to 88.75% before surgery, and the rate of surgery was increased from 85.29% to 96.20% before medical record management moved forward. The grade B medical records from the 68% to 68% before the move, B grade medical records from 30% to 0.87%, C grade records from 2% to 0.03%, respectively, Grade A medical records increased from 50.2% to 64.2%, 42.3% to 35.2% and Grade C to 0.6%, and there was significant difference. Conclusion The model of medical records management can improve the quality of medical records, reduce medical disputes and improve the archival rate of medical records on the 7th, can be used in hospitals.