某院肿瘤化疗病历现状与质量改进

Status and Quality Improvement of Medical Records on Tumor Chemotherapy in a Hospital

目的了解某院肿瘤化疗病历质量现状,查找分析问题,探讨对策,为医院改善病历质量,加强管理提供参考依据。方法 2016年肿瘤化疗病历共14 301份,分层随机抽取722份进行专项督查,汇总分析督查结果,针对问题提出整改措施。结果肿瘤化疗病历自查优良率仅65.1%,整体质量一般。居前三位的分别为,化疗适应证、禁忌证记录不完整,占20.7%;化疗药物应用记录不规范,占17.6%;化疗后的疗效评价及记录不完整,占13.5%。结论通过对肿瘤化疗病历专项督查及对策研究,形成管理方案,有效规范肿瘤化疗诊疗行为与病历书写,提升医疗质量,保障医疗安全。

Objective To know the status of medical records quality on tumor chemotherapy in a hospital,find and analyze problems,and explore the countermeasures so as to provide reference for hospitals to improve the quality of medical records and strengthen the management. Methods There were 14301 medical records of tumor chemotherapy in 2016. We selected a stratified random sample of 722 copies for specific inspection,summarized and analyzed of test results,and put forward rectification measures in view of the problems. Results The good rate of tumor chemotherapy medical was only 65. 1%. The overall quality is general. The top three questions were incomplete chemotherapy indications and contraindications record（ 20. 7%）,unstandardized record of chemotherapy drugs（ 17. 6%）,incomplete record of effect evaluation after chemotherapy（ 13. 5%）. Conclusion Through the special inspection and countermeasure research of tumor chemotherapy,we formed a management plan to effectively regulate the behavior of the tumor chemotherapy treatment and medical record writing,improved the quality of medical treatment,and ensured medical safety.