医护一体化运行病历管理在泌尿外科患者中的效果研究

Effect of medical record management of integrated medical and nursing operation on patients in Department of Urology

目的探讨医护一体化运行病历管理在泌尿外科患者中的效果。方法选取2016年7~12月泌尿外科24名为对照组,2017年1~6月泌尿外科24名医护人员为观察组,观察组实行医护一体化运行病历管理模式,对照组实行常规的运行病历管理模式。不定期抽查两组运行病历,比较两组缺陷病历发生率,主要缺陷项目发生率以及患者填写各项知情同意书时对医护人员的满意程度。结果观察组患者总运行病历缺陷项目发生率为57%,对照组为86%,差异具有统计学意义(P<0.05);规范培训后,观察组医护人员考核合格率为95.83%,对照组医护人员为83.33%,差异具有统计学意义(P<0.05);患方填写各项知情同意书时对观察组医护人员总体满意率为87.5%,对对照组医护人员总体满意率为78.1%,差异具有统计学意义(P<0.05)。结论医护一体化运行病历管理模式有助于提高运行病历质量,促进医护人员沟通,提高患者满意度。

Objective To explore the effect of integrated medical record management in patients in Department of urology. Methods Twenty-four medical care workers in Department of urology from July 2016 to December 2016 were selected as the control group, and 24 medical nurses from January 2017 to June 2017 were selected as the observation group. The observation group received medical record management of integrated medical and nursing operation, while the control group received routine medical record management mode. Medical records of two groups received unscheduled examination. The incidence of defective medical records, the incidence of major defective items, and satisfaction degree of the patients when they filled in the informed consent form were compared. Results The total incidence of defective items in the observation group was 57% and 86% in the control group, with significant difference（P〈0.05）. After standardized training, the qualified rate of medical staff in the observation group was 95.83%, while that in the control group was 83.33%, and the difference was statistically significant（P〈0.05）. The overall satisfaction rate for the medical and nursing staff in the observation group was 87.5%, and the total satisfaction rate for the medical and nursing staff in the control group was 78.1%. The difference was statistically significant（P〈0.05）. Conclusion The integrated medical record management mode helps to improve the quality of medical records, facilitate communication between medical staff and patients, and improve patient satisfaction.