手术科室病案首页的多层面质量管理实践

Multi-level quality management of the medical record home page for the surgery departments

目的手术科室病案首页具有其特点,本研究拟通过比较某院在实施多层面病案质量管理前后的手术科室病案首页质量情况,归纳总结提高手术科室病案首页质量的管理方法。方法某院自2020年6月起,逐步开展基于科室首页特点的多层面病案首页质量管理,本研究选取2020年1-6月11613份手术科室病案为对照组,2020年7-12月17162份手术科室病案为观察组,分析和比较两组病案的首页合格率和首页各质控项目缺陷情况。结果与对照组相比,观察组病案首页合格率明显提高(99.03%vs 96.84%,P<0.001),且观察组病案各项首页质控项目缺陷情况显著改善(P<0.05)。此外,与对照组相比,观察组病案首页的手术栏缺陷构成比(10%)和其他诊断缺陷构成比(22%)分别升高了4%和3%。结论基于科室病案首页特点的多层面质量管理能显著提高手术科室首页质量,应将手术栏和其他诊断栏填写质量作为手术科室首页质控的重点。

Objective The home page of the surgery departments has some characteristics.This study aimed to compare the quality of the home page for the surgery departments before and after the implementations of multi-level medical record quality management,and summarize the management methods to improve the quality of the home page for the surgery departments.Methods Since June 2020,a hospital gradually carried out multi-level quality management of home page based on department characteristics.This study selected 11613 surgical medical records from January to June 2020 as the control group,and 17162 surgical medical records from July to December 2020 as the observation group.The qualified rate of the two groups and the defects of each quality control item on the home page were analyzed and compared.Results Compared with the control group,the qualified rate of the observation group was significantly improved(99.03%vs 96.84%,P<0.001),and the defects of the quality control items of the observation group were significantly improved(P<0.05).In addition,compared with the control group,the defect ratio of the surgical column(10%)and other diagnostic defects(22%)in the home page of the observation group increased by 4%and 3%,respectively.Conclusion Multi-level quality management based on the characteristics of the home page of different departments could significantly improve the quality of the home page for the surgery departments.The quality of the operation column and other diagnostic columns should be the focus of the quality control for the surgery departments.