强化病案质量检查评价提高病案整体质量

Strengthening the Quality Check and Evaluation of Medical Records to Improve the Overall Quality of Medical Records

目的探究病案质量检查评价,提高病案整体质量的方法。方法选取该院2019年5-11月收治的400份病案为研究对象,以实施强化病案质量检查评价为分界点,将其分为A组和B组,各200份,其中B组为常规病案管理组,A组为病案质量检查评价管理组。两组病案管理区分界线为2019年9月,2019年9月后该院实施强化病案质量检查评价方法,转变传统病案管理形式,对比病案管理情况及病案管理事故发生率。结果 A组病案管理情况评价要好于B组,且A组病案管理事故发生率显著低于B组(P<0.05)。结论 A组在强化病案质量检查评价管理方法实施后,病案管理质量和病案管理水平得到了显著的提升,且在病案管理过程中,出现病案管理差错的几率显著降低,同时对于病案管理的基本情况处置效果也得到了显著的提升。

Objective To explore the methods of medical record quality inspection and evaluation to improve the overall quality of medical records. Methods The 400 medical records received in the hospital from May to November 2019 were selected as the research objects, and the intensive medical record quality inspection and evaluation was used as the dividing point. They were divided into group A and group B, each with 200 copies, of which group B with the routine medical record management group, and the group A with the medical record quality inspection and evaluation management group. The dividing line between the two groups of medical records management was September After September 2019, the hospital would implement intensive medical record quality inspection and evaluation methods, change the traditional medical record management form, and compare the medical record management situation and medical record management accident rate.Results The evaluation of case management in group A was better than that in group B, and the incidence of accident management in group A was significantly lower than that in group B(P<0.05). Conclusion After the implementation of the strengthened medical record quality inspection and evaluation management method in group A, the quality of medical record management and the level of medical record management have been significantly improved. In the process of medical record management, the probability of medical record management errors has been significantly reduced. The situation treatment effect has also been significantly improved.