应用出院记录量表评估某院儿科出院病案书写质量分析

Application of Discharge Records Scale to Assess the Quality of Written Records of Pediatric Discharge in A Hospital

目的探讨提高临床医师出院记录书写质量的对策。方法应用出院记录评分量表,对某院儿科医师在住院医师期间的出院病案进行量化评估,按照评价标准进行专项定量质控,将质控结果录入Excel表中进行统计分析。结果按照出院记录评分量表分别对6名儿科医师担任第1～5年住院医师期间,每人每年各20份共600份出院记录进行评分,采用非参数检验对不同年资住院医师出院记录总分统计分析,除第4年组与第5年组差异无统计学意义(P>0.01);其余各组间的平均轶的差异有统计学意义(P<0.01)。出院记录评分量表中16项书写内容逐项评分,专项均值低于3分的书写内容项目集中在:治疗经过、病情演变、住院期间用药及治疗期间药物更换说明。结论出院记录量表为临床医师规范书写出院记录提供了参考标准,不同年资住院医师的出院记录书写质量均需亟待提高。

Objective To improve the writing quality of the pediatric discharge summaries. Methods The discharge records of pediatricians in a hospital were evaluated quantitatively by using the discharge summary quality assessment tool. The quality control was carried out according to the evaluation standard, and the quality control results were recorded into the Excel table for statistical analysis. Results According to the report of the discharged records, 6 pediatricians were rated as the lth to 5th year resident, each 20 total of 600 discharge records per person per year, and the statistical analysis of the total score of the discharged records of different years of residency was performed by nonparametric test, the 4th and 5th year group was no statistically significant difference （P〉0.01）,the difference in average anecdotes was statistically significant （P〈0.01）. The contents of 16 items in the discharge record assessment form were graded, and the items with a specific average of less than 3 were focused on： treatment, progression, medication during hospitalization, and drug replacement instructions during treatment. Conclusion The discharge summary quality assessment tool provides a reference standard for clinicians to write discharge. The quality of discharge records of residents with different seniority needs to be improved.