某院抗菌药物病历书写方法研究

Study on the Writing Method of Antibacterials Medical Records in a Hospital

目的采用品管圈活动的形式,加强某院抗菌药物病案质量管理,减少抗菌药物病历书写缺陷,提高抗菌药物病案管理水平。方法成立品管圈活动小组,确立活动主题,按照活动程序,抽取某院2015年1月至12月治疗性应用抗菌药物病案800份,分析其中存在的问题,探讨出现不合理应用的原因并进行干预,与2016年1月至12月开展品管圈活动后抗菌药物病案合理应用情况进行比较。结果通过开展品管圈活动,抗菌药物病历书写合格率从83.4%提到到94.8%,较预先设定的目标值94.56%增加0.24%。其中,改进组特殊使用级抗菌药物会诊单填写不规范35例次,占比4.38%,不合格率较基线组降低12.0%;抗菌药物使用72小时后未评价5例次,占比0.63%,不合格率较基线组降低9.62%;抗菌药物使用前未合理推断致病原8例次,占比1.0%,不合格率较基线组降低6.3%;其他不合格事项共计4例次,占比0.5%,不合格率较基线组降低7.13%。结论将品管圈活动运用到抗菌药物病案管理中,可以不断发现和解决抗菌药物病案管理工作中存在的问题,是实现抗菌药物病案科学管理的有效途径和方法。

Objective Using quality control circle activities to strengthen the quality management of antibacterial drugs in a hospital, reduce the defects of medical record writing, and improve the level of antimicrobial drug records management. Methods The establishment of QCC team, establish the theme of the activities in accordance with the procedures, selected in a hospital from January 2015 to December the treatment of antibiotics 800 medical records,analysis the existing problems, to explore the reasons for the unreasonable application and intervention, and from January 2016 to December open circle activities exhibits antimicrobial agents of rational use of medical records comparison. Results Through carrying out quality control circle activities, the qualified rate of medical record writing was raised from 83.4% to 94.8%. Increase 0.24%. than pre set target value 94.56%. Among them, the improvement group＇s special use level antimicrobial consultation list was nonstandard filled in 35 cases, accounting for 4.38%.Failure rate decreased by 12.0% compared with baseline group. After 72 hours of use of antibiotics, 5 cases were not evaluated, accounting for 0.63%. The rate of disqualification was 9.62% lower than that in the baseline group. Prior to the use of antibacterial drugs, 8 cases were not presumed to be pathogenic, accounting for 1.0 %. The rate of disqualification was 6.3% lower than that in the baseline group. The number of other nonconformance matters was 4, accounting for 0.5%. The rate of disqualification was reduced by 7.13% compared with the baseline group. Conclusion The application of quality control circle activities in the management of antibiotics medical records can continuously find and solve the problems, and it is an effective way to achieve the scientific management of antibiotics medical records.