单项否决病案分析与改进

Analysis and Countermeasures of Medical Records with Single-Item Veto in Hospital

目的通过分析2016年单项否决病案产生的原因,提出应对措施,以提高病案书写质量。方法采取普查法,并对质控结果进行统计学分析。结果单项否决病案中"缺整页病历记录造成病案不完整"占比最高(62.80%),医嘱单和体温单缺失最严重,手术科室缺陷明显多于非手术科室。结论单项否决病案缺陷项目原因有多环节病案质控把关不严,病例重点内容监控不到位,医护工作流程衔接不流畅,特殊区域监管存在缺陷等。建议加强环节指控,发挥指控员作用;提高认识,严格落实奖惩措施;改善工作流程,加强医护间协作;应用质量管理工具,促进病案质量持续改进;落实病案四级指控体系,制定特殊区域管理办法等。

Objective To countermeasures to improve the analyze the causes of the medical records with single--item veto in 2016 and propose writing quality of medical records. Methods The census method was used, and the stically analyzed. Results Among the medical records with single--item veto, the un- ack of a whole page record had the highest proportion （62.80%）, the loss of orders and t serious conditions, and the surgery departments had obviously more defects than that of non--surgical departments. Conclusion The reasons for the medical records with single--item veto included lax quali ty control of medical records, irresponsible supervision on the important content of patients, the unsmooth connection of medical workflow, deficiencies in special regional regulat links quality control, and take effect of the quality control ion, etc. Suggestions were proposed, including to strengthen staff; to improve awareness and strictly implement the reward and punishment measures; to improve work flow and strengthen medical cooperation; to apply quality management tools to promote continuous improvement of the quality medical records; to implement the four--level quality control system on medical records and develop special regional management methods