病案管理中存在的问题及质量控制措施

Problems in the Management of Medical Records and Quality Control Measures

目的探析病案管理中存在的问题及质量控制措施。方法选取2021年1-6月期间该院医务人员10名及住院患者的1000份病案进行分析,将其纳入研究组,实施强化病案管理措施。选取2020年7-12月期间该院医务人员10名及住院患者的1000份病案进行分析,将其纳入参比组,实施基础病案管理措施。分析不同组别病案管理后的管理措施了解情况、问题发生率、甲级病案率。结果研究组管理后的管理措施了解情况高于参比组,差异有统计学意义(P<0.05);研究组管理后的问题发生率低于参比组,差异有统计学意义(P<0.05);研究组管理后的甲级病案率高于参比组,差异有统计学意义(P<0.05)。结论在对住院患者的病案进行管理时,使用强化病案管理措施能够提升医务人员的管理措施了解情况,降低问题发生率,提高甲级病案率,建议为住院患者进行病案管理时应用。

Objective To analyze the problems in medical record management and quality control measures.Methods 10 medical staff and 1000 medical records of hospitalized patients in the hospital from January to June 2021 were selected for analysis,and they were included in the study group to implement measures to strengthen medical record management.10 medical staff and 1000 medical records of hospitalized patients in the hospital from July to December 2020 were selected for analysis,and they were included in the reference group to implement basic medical record management measures.The management measures after the management of different groups of medical records were analyzed to understand the situation,the incidence of problems,and the rate of grade A medical records.Results The understanding of management measures in the study group after management was higher than that in the reference group,and the difference was statistically significant(P<0.05);the incidence of problems after management in the study group was lower than that in the reference group,and the difference was statistically significant(P<0.05);the rate of Grade A cases after management in the study group was higher than that in the reference group,and the difference was statistically significant(P<0.05).Conclusion In the management of medical records of inpatients,the use of enhanced medical record management measures can improve the understanding of the management measures of medical staff,reduce the incidence of problems and increase the rate of Class A medical records,it is recommended to apply when medical records are managed for inpatients.