某肿瘤专科医院不同科室病案质量缺陷分析及对策

Analysis and Countermeasures of the Quality Defects of Medical Records of Different Departments in a Cancer Hospital

目的深入了解某院病案质量现状,分析缺陷分布及成因,探究提高病案质量的有效途径及管理对策,为医院病案质量管理提供参考。方法抽取2016年度环节病案与终末病案,对手术科室与非手术科室病案缺陷进行对照评价,应用SPSS11.0统计软件对数据进行分析。结果 2016年终末病案甲级病案率88.80%,环节病案不合格率32.70%。手术科室缺陷率较高,非甲级病案发生与专业存在一定关联性,手术系列科室的非甲级病案发生概率(13.79%)明显高于非手术科室(8.09%),环节病案不合格病案发生概率(42.42%)明显高于非手术科室(21.02%),两组比较差异有统计学意义(P=0.000)。结论应采取加强对医务人员的培训,利用电子病历实现病案质量监控与层级质量管理,开展闭环管理等有效的管理措施,进一步提高病案书写质量。

Objective To understand the present situation of medical record quality in a hospital, analyze the distribution and cause of defects, explore the effective way and management countermeasure to improve the quality of medical record, and provide reference for the quality management of hospital medical record. Methods The data were analyzed by SPSS 11.0 statistical software. Results In 2016, the final Grade A medical record rate was 88.80,the link medical record unqualified rate was 32.70. The defect rate of the surgical department was high, and the non-A medical record had a certain correlation with the specialty. The probability of occurrence of non-grade A medical records in surgical departments was significantly higher than that in non-operative departments（13.79%）.The probability of unqualified medical records was 42.42, which was significantly higher than that of non-operative departments（21.02%）. The difference between the two groups was statistically significant（P=0.000）. Conclusion We should strengthen the training of medical personnel, use electronic medical records to realize effective management measures such as medical record quality monitoring and level quality management, carry out closed-loop management and so on, and further improve the quality of medical record writing.