基于帕累托原理的运行病历质量控制

Quality Control of Running Medical Records Based on Pareto Principle

目的分析运行病历中主要缺陷及表现,探讨提高运行病历书写质量的方法。方法 2016年7月-2017年4月对某院3400份运行病历进行质控,将存在的3674条问题运用帕累托原理进行分析,明确影响运行病历质量的主要原因。结果 11类缺陷类别中,病程记录内容缺陷、入院记录内容缺陷、医患沟通记录及重要知情同意书内容缺陷、围手术期记录内容4类缺陷类别为主要缺陷类型,累积百分比为79.38%。结论从健全病历质控体系,统一质控标准,明确奖惩办法,加强医师培训,注重提升信息化建设水平入手,将质控重点转移到病历书写内涵上,逐步实现精细化管理,从而达到更好防范医疗风险和提升医疗质量管理水平的目的。

Objective This paper analyzes the main defects and manifestations in running medical records, and probes into the methods for improving the quality of medical records. Methods From July 2016 to 2017 April, 3400 medical records of a hospital were tested and analyzed. The 3674 problems were analyzed by Pareto＇s principle, and the main reasons affecting the quality of medical records were confirmed. Results 11 kinds of defects, the content of course record defects, defects of contents, the admission records of doctor-patient communication records and important content of informed consent defects, perioperative records of 4 kinds of defects is the main defect types,the cumulative percentage is 79.38%. Conclusion We should improve the medical quality control system, unified quality standards, clear rewards and punishments measures, strengthen the training of doctors, focus on improving the level of informatization construction, quality control will shift the focus to the medical connotation, and gradually realize the refinement of management, so as to better to prevent medical risk up to the level of medical quality management.