医疗质量管理中归档病历管理的价值

The Value of Archived Medical Records Management in Medical Quality Management

目的探讨在医疗质量管理中归档病历管理的价值。方法对2019年和2020年各抽取1000份病历评分单予以回顾性分析,2019年按照常规要求和规定对病历进行归档和管理,2020年强化归档病历管理工作,对2019年和2020年归档病历中甲级病历率进行分析和对比,并对2019年和2020年乙级病历缺陷构成进行分析和对比,另外对评分单中内涵扣分比予以分析,分析病历内涵扣分比及质控情况。结果从甲级病历率分析发现,2019—2020年病历归档中甲级病历率得到提升,2019年甲级病历率达到89.0%,2020年甲级病历率达到96.0%,2020年甲级病历率明显高于2019年,差异有统计学意义(P<0.05)。从乙级病历缺陷分析,2019年乙级病历缺陷率达到5.0%,2020年乙级病历缺陷率为2.6%,2019年乙级病历总缺陷率和2020年乙级病历总缺陷率对比,差异有统计学意义(P<0.05);在累计扣分在10分以上的乙级病历缺陷率上,2019年为2.6%,2020年为2.0%,两个时间段对比差异无统计学意义(P>0.05)。对单项否决项的乙级病历缺陷构成进行分析,2019年单项否决项乙级病历总缺陷率为2.4%,2020年单项否决项乙级病历总缺陷率为0.6%,两个时间段对比差异有统计学意义(P<0.05);但从代签名未签名、血型错误、缺检查检验报告单3项单项否决项单独对比分析,2019年和2020年对比差异无统计学意义(P>0.05)。从病历内涵质控分析,2019年和2020年在病历内涵扣分比对比,差异有统计学意义(P<0.05);在格式扣分、内涵扣分上2019年和2020年对比,差异有统计学意义(P<0.05)。结论在医疗质量管理中,归档病历管理的实施可以提高病历质量,特别是病历内涵质量,促进质量控制管理体系的进一步发展。

Objective To explore the value of archived medical records management in medical quality management.Methods A retrospective analysis of 1000 medical record score sheets in 2019 and 2020 were performed.In 2019,medical records were archived and managed in accordance with routine requirements and regulations.In 2020,the management of archived medical records was strengthened,and medical records were archived in 2019 and 2020.Analyzed and compared the rate of Grade A medical records,analyzed and compared the defect composition of Grade B medical records in 2019 and 2020,and analyzed the connotative deduction ratio in the score sheet,analyzed the connotation deduction ratio of medical records and the quality control situation.Results From the analysis of the rate of Class A medical records,it was found that the rate of Class A medical records in medical records archived from 2019 to 2020 has been improved,the rate of Class A medical records in 2019 will reach 89.0%,the rate of Class A medical records in 2020 will reach 96.0%,and the rate of Class A medical records in 2020 was significantly higher than in 2019,the difference was statistically significant(P<0.05).Based on the analysis of the defects of Grade B medical records,the defect rate of Grade B medical records in 2019 reached 5.0%,the defect rate of Grade B medical records in 2020 was 2.6%,and the total defect rate of Grade B medical records in 2019 and the total defect rate of Grade B medical records in 2020 were statistically compared,the difference was statistically significant(P<0.05);in terms of the defect rate of Grade B medical records with cumulative deduction of more than 10 points,it was 2.6%in 2019 and 2.0%in 2020.There was no statistical difference between the two time periods(P>0.05).Analyzed the composition of the defects in the grade B medical records of the single veto items.In 2019,the total defect rate of the single vetoed grade B medical records was 2.4%,and the total defect rate of the single vetoed grade B medical records in 2020 was 0.6%.There were statistics for comparison between the two time periods.The difference was statistically significant(P<0.05);but the three single rejection items of unsigned from generation,wrong blood type,and lack of inspection report were separately compared and analyzed.There was no statistical difference between 2019 and 2020(P>0.05).From the analysis of the quality control of the medical records,there was a statistical difference in the comparison of the medical record deduction ratio between 2019 and 2020,the difference was statistically significant(P<0.05);there were statistical differences in the format deduction and the connotation deduction between 2019 and 2020,the difference was statistically significant(P<0.05).Conclusion In medical quality management,the implementation of archived medical records management can improve the quality of medical records,especially the quality of medical records,and promote the further development of the quality control management system.