提高我院三级及四级手术病历质量的实践探讨

Improving the quality of medical records for grade Ⅲ and Ⅳ surgeries at our hospital

目的探讨提高三、四级手术病历质量的对策。方法对2017年1月~2017年5月采用《住院病历环节质量评分表》抽检的267份三、四级手术病历进行缺陷分析,并根据缺陷制定《手术病历质量检查评分表》及其他干预对策,比较干预前后的三、四级手术病案质量。结果使用《手术病历质量检查评分表》进行专项检查及一系列干预措施前,即2017年1月~5月抽查的三、四级手术病历缺陷率为71.16%;增加使用《手术病历质量检查评分表》及其他措施实施后,即2017年6月~12月,病历缺陷率降至48.57%;妇科、肛肠科、骨科、眼科及小儿外科在干预措施实施后的缺陷病历率下降幅度较大,病历的主要缺陷问题也明显下降。结论通过制定适用的检查标准、完善病案质量管理体系及电子病历信息系统、定期开展医疗质量及病历书写培训、建立得当的奖惩激励机制、加强科级病历质控管理等对策的实施,可有效降低三、四级手术病历的缺陷发生率,提高三、四级手术病历及医疗管理质量。

Objective To explore the countermeasures to improve the quality of medical records for grade III and IV surgeries at our hospital.Methods Medical records of 267 patients,selected using the Hospitalization Medical Record Quality Scoring Scale,who underwent grade III and IV surgeries at our hospital from January to May 2017 were reviewed.A“Surgical Record Quality Scoring Scale”and other interventions were developed based on the defects found.The quality of the medical records before and after intervention was compared.Results The defect rate of the medical records of grade III and IV surgeries was 71.16%during the preintervention period from January to May 2017.After intervention from June to December 2017,the defect rate decreased to 48.57%.In particular,the defect rates of medical records were significantly decreased in the departments of gynecology,anorectology,orthopedics,ophthalmology,and pediatric surgery,and the major defects in medical records were also reduced significantly.Conclusions Interventions,including developing applicable inspection standards,and quality management system and electronic medical record information system,conducting regular training on medical quality and medical record writing,establishing appropriate incentive mechanisms,and strengthening department-level quality control of medical records,can effectively reduce the defect rate of medical records for grade III and IV surgeries and improve the quality of medical records and medical service management.