住院病案质量分析与对策研究

Quality Analysis and Countermeasure Study of Inpatient Medical Records

目的通过对出院病案存在的缺陷进行分析,查找原因,提出改进措施,达到持续提高目的,减少医疗纠纷,确保医院声誉及患者安全。方法按出院病案15%以上的比例,对医院2016年度各科室出院病案进行随机抽查,对照江苏省及医院制定的检查评分标准进行打分,采用卡方检验、logistic回归分析统计方法,分析检查结果。结果 2016年抽查出院病案5250份,合格病案4768份,不合格病案482份,病案合格率为90.8%,有转科情况出现不合格病案是无转科者的7.729倍(P=0.001),医师工作量大出现不合格病案是医师工作量正常者的3.334倍(P=0.002),而病案住院时间<10天出现不合格病案仅是病案住院时间>21天者的0.021倍(P<0.001)。结论有转科情况、医师工作量大和住院时间长对病案质量影响较大。对此,应加强病案书写规范培训,重点关注有转科、长时间住院和工作量大科室的病案书写,加强各级医务工作者的质量意识,从而持续提高病案书写质量。

Objective Trough analysis of the flaws of the hospital medical record quality,to find the reasons,put forward the improvement measures, achieve the purpose of continuous improvement and reduce medical disputes,ensure the hospital reputation and patient safety. Methods The proportion of more than 15% medical records of discharged hospital in 2016 were randomlychecked. Marking scores according to check standard for evaluation of Jiangsu province and the hospital. Using the chi square test, logistic regression analysis to analyze the test results.Results In 2016, there were 5250 cases of discharged medical records, 4768 qualified medical records,482 unqualified medical records. The qualified rate of medical record is 90.8%. The advantage of unqualified medical record in transfer caseis 7.729 times of non-transfer case（P=0.001）. The advantage of unqualified medical record in Physician workloadis 3.334 times of the normal workload of the physician case（P=0.002）. The advantage of unqualified medical record inthe hospitalization time less than 10 days caseis 0.021 times of the hospital stay more than 21 days case（P〈0.001）.Conclusion Transfer, physician workload and long hospitalization time has great influence on the quality of medical records. In this regard, strengthening the standardization of medical records writing training, focus on transfer, long time hospitalization and workload department medical record writing, strengthen quality awareness at all levels of medical workers, so as to continuously improve the quality of medical records writing.