会诊病程记录书写缺陷分析及干预效果评价

Analysis on the Writing Defects in the Course of Consultation and Evaluation of the Effect of Intervention

目的分析会诊病程记录的缺陷,以加强病案质量管理,保障医疗安全。方法 2018年3月-2018年7月,每月随机抽取每科室5例会诊完成病历,对会诊病程记录书写进行检查汇总,进一步分析。结果在检查的1139份会诊病程中,合格912份,合格率80.07%。会诊病程记录书写缺陷以无记录最多,为87份,占总检查量的7.64%,其次复制粘贴的72份,占比6.32%,最少为病程记录不完善的68份,占比5.97%。经过干预措施,总合格率由2018年3月的73.87%上升到2018年7月的87.50%。非手术科室合格率为91.25%,高于手术科室的85.16%。结论会诊病程记录质量,经过科学全面监管与重点教育相结合的途径能得到有效改善,其中非手术科室提高相对手术科室比较显著。

Objective To analyze the defects in the course record of consultation so as to strengthen the quality management of medical records and ensure medical safety. Methods From march to July 2018, 5 cases of each department were randomly selected every month to complete the medical records of the consultation, and the records of the course of the consultation were reviewed and summarized for further analysis. Results Of the 1,139 sessions examined, 912 were qualified, with a qualified rate of 80.07%. Among the defects, 87 were unrecorded, 72 were copied and pasted, and 68 were incompleted, accounting for 7.64%, 6.32%, 5.97% respectively. After intervention measures, the total pass rate increased to 87.50% from 73.87% in March. The qualified rate of non-surgery department was 91.25%, higher than surgery department（85.16%）. Conclusions The quality of the course record of the consultation could be effectively improved through the combination of scientific and comprehensive supervision and key education, among which the improvement of non-surgical department was relatively stable compared with surgical department.