12576份终末疗案存在的缺陷分析及应对策略

Defects Analysis and Improvement on 12576 Cases of Terminal Recuperating Records

目的通过对疗养中心缺陷疗案进行全面分析,查找缺陷发生的原因及分布情况,针对性提出改进措施,以提高终末疗案质量。方法对某疗养院2019年1月1日-2020年12月31日期间的12576份终末疗案,按照规范要求逐份进行质量检查,对缺陷问题进行整理分析,计算各科室疗案缺陷率及各种缺陷占比进行反馈。结果12576份终末疗案中1104份存在缺陷,康复科疗案缺陷率为18.8%。各类缺陷共计1267项,其中基本要求缺陷292项,占23.05%;疗案首页缺陷160项,占12.63%;体格检查及疗养记录缺陷279项,占22.02%;疗程记录缺陷410项,占32.36%;各类检查治疗单、会诊单缺陷126项,占9.94%。排名前三的缺陷类型为医师签名不全、不规范,疗程记录内容不全、不准确,医嘱、治疗用药不规范,分别占9.31%,8.29%,8.13%。不同疗养科室疗案缺陷类型不尽相同,但差别不明显。结论疗案质量是评价医疗质量管理的核心,通过对重点科室的监控、强化人员培训、加强质控管理、建设规范化疗养路径及促进信息化建设等综合措施,以进一步提升疗案质量。

Objective Through the analysis of defect recuperating records,we finded out the reasons and distribution,and putted forward improvement measures to reduce defect recuperating records and improve the quality.Methods We conducted examination on 12576 cases of archived recuperating records from January 1,2019 to December 31,2020,then processed and analyzed the defect rate of treatment Cases in departments to calculate the proportion of them.Results 1104 of 12576 cases were defective,The defect rate of rehabilitation cases was 18.8.A total of 1267 defects,there were 292 defects of basic requirements,accounting for 23.05% of the total defects;160 defects of the first page,accounting for 12.63% of the total defects;279 defects of physical examination and recuperating records,accounting for 22.02%;410 defects of treatment process records,accounting for 32.36%and 126 defects of examination report sheets,accounting for 9.94%.The top three types of defects were defects of handwriting signature,defects of treatment process records and defects of doctor’s advice,accounting for 9.31%,8.29%,8.13% respectively.The types of defects in different convalescent departments are different,but the difference is not obvious.Conclusion The quality of recuperating records is the core of medical quality management.Through monitoring of key departments,comprehensive measures such as strengthening training,strengthening quality control management,constructing standardized nursing path and promoting information construction should be taken to further improve the quality of recuperating records.