胸外科病案质量缺陷分析及改进

Analysis and Improvement of Quality Defects of the Thoracic Surgery Medical Records

目的对医院胸外科住院病案缺陷的原因进行探讨分析,从胸外科专科角度针对主要相关问题提出改进措施,并进行研究评价。方法审核胸外科2018年1月-12月1274份归档病案,对反馈的缺陷病案进行分析;提出改进办法。改进后2019年1月-2019年6月687份病案,经同一组病案质控人员审核,结果与改进前进行比较研究,并使用SSPS13.0统计软件分析。结果改进前缺陷病案55份(4.3%,55/1274),共存在问题73处,主要包括病案首页填写问题28处(38.4%);病历书写不规范21处(28.8%)。分析原因并提出模块化培训+督导+沟通的改进措施。改进后缺陷病案9份(1.3%,9/687),显著低于改进前(P≤0.001)。改进后共存在问题18处,其中病案首页填写问题6处(33.3%);病历书写不规范5处(27.7%)。缺陷问题构成比无显著差异(P>0.05),但是错误种类明显减少。结论病案首页填写缺陷和病历书写不规范是影响胸外科病案质量的主要因素,模块化培训与督导和沟通相结合有助于提高胸外科医师的病历书写质量。

Objective To analyze the causes of in-patient thoracic surgery medical records defects,from the perspective of thoracic surgery specialty,put forward the improvement measures for the main related problems and evaluated the effect later.Methods By analyzing defective medical records from January to December 2018,a total of 1274 thoracic surgery medical records,putting forward countermeasures.After implementing improvement measures,comparing the quality of medical records from 2018 and from January to June 2019,a total of 687 thoracic surgery medical records that were examined by the same group of medical record quality control personnel and conducting statistical analysis with the SPSS 13.0 software.Results 55 defective medical records were discharged before improvement,the total defect rate was 4.3%,and the defective items were 73,among them,28 were front page defects,accounting for 38.4% of the total defects;21 were irregular in medical records,accounting for28.8%.Analyzing the causes of medical record defects and putting forward the improvement measures of "modular training+supervision+communication".9 defective medical records were discharged after improvement,the total defect rate was 1.3%,lower than those before improvement(P≤ 0.001).There were 18 defective items after improvement,of which 6 were front page defects,accounting for 33.3%,5 were irregular,accounting for 27.1%.There was no significant difference in defect composition ratio(P>0.05),but the types of defects were significantly reduced.Conclusion The front page defects and the irregular writing in medical records are main factors affecting the quality of thoracic surgery medical records.The combination of modular training,supervision and communication can improve the quality of thoracic surgery medical records.