中医运行病历质量控制方法探讨

Discussion on the Quality Control Method of Medical Records of Chinese Medicine

目的通过对中医院运行病历质量评价标准的研究,提高中医病案质量。方法回顾某中医院2006年-2010年住院运行病历环节质控情况,并用问卷调研、访谈的方法,征求临床医师意见,探讨中医病案质量评价标准。结果 5年间运行病历检查发现问题共5876条,中医内涵质量缺陷占13.85%,集中在四诊信息、辨病辨证依据、理法方药、上级医师查房等方面。共回收有效问卷249份,调查结果显示85%以上的医师认同医院现行的病案质量评价标准,书写病历的下级医师重视病案的实用性,上级医师更注重病案内涵及学术研究价值。结论中医运行病历质控应围绕医疗安全核心制度,建立全国统一标准,突出体现中医内涵特色,在保证病案质量的基础上,平衡各项检查项目的权重,使评价标准更切合临床实际。

Objective To improve the quality of medical records through the study of the evaluation standard of medical records of Chinese hospitals. Methods To review the quality control situation of hospital medical records in a hospital from 2006 to 2010, and use questionnaire survey and interview method were applied to solicit the opinions of clinicians to discuss the quality evaluation criteria of TCM medical records. Results In the past five years, there were 5,876 cases of medical records and 13.85% of the quality defects of TCM, which focused on four diagnostic information, discrimination basis of disease differentiation, rational prescription drugs, and superior physician＇s inspection. Recycling effective questionnaire 249, the survey found that more than 85% of physicians agreed that a hospital＇s current medical record quality evaluation standard, writing case of junior doctors pay attention to is practical, the superior doctors pay more attention to the connotation of the medical record and the value of academic research. Conclusions The operation of medical record quality control of traditional Chinese medicine should be centered around the nucleus of medical security system, establish a unified national standards, highlighting connotation characteristics of traditional Chinese medicine, on the basis of guarantee the quality of medical records,balance the weight of each inspection project, make evaluation criterion to be more relevant to clinical practice.