厦门市某院恶性肿瘤化疗患者住院分布情况及其病历质控结果比较

The Distribution of Inpatients with Malignant Tumor Chemotherapy and the Comparative Analysis of Quality Control Results of Medical Records in a Certain Hospital in Xiamen

目的:分析我院恶性肿瘤化疗患者的住院分布情况,对改进前后肿瘤化疗病历质控结果进行比较,为进一步规范我院肿瘤化疗提供科学依据。方法:选取2017年1月~2018年6月和2019年1月~2020年6月期间我院的肿瘤化疗病历,后期加强了质控。回顾性分析前述时间段内我院每季度肿瘤化疗病历的抽查质控结果,比较改进前后病历抽查质控结果。结果:我院化疗病历中排名前4位的肿瘤分别为:肺恶性肿瘤、乳腺恶性肿瘤、食管恶性肿瘤及宫颈恶性肿瘤;改进后各科室的肿瘤化疗病历平均分比改进前均有提高,差异均有统计学意义(均P <0.05);改进后病理诊断、肿瘤分期、化疗适应症、化疗方案合理性、化疗方案制定者职称、化疗药物的选择及剂量、记录身高体重体表面积、按照体表面积或AUC计算药物剂量、化疗药物用法(包括预处理方案)、不良反应监测、不良反应处理、化疗观察表、疗效评价(≥2周期)及化疗知情同意书的完善率均高于改进前的完善率,差异均有统计学意义(均P <0.05)。结论:我院通过制定肿瘤化疗标准,加强医生的培训,完善化疗前小结模板及举办肿瘤化疗研讨会等改进措施,使化疗过程更规范,提高了肿瘤化疗的质量,保障了患者安全。

Objective:To investigate the distribution of inpatients with malignant tumor chemotherapy and the comparative analysis of quality control results of their medical records in a certain hospital in Xiamen. Provide a scientific basis for further standardizing tumor chemotherapy in our hospital. Methods:The medical records of tumor chemotherapy in our hospital from January 2017 to June2018 and January 2019 to June 2020 were selected respectively,enhanced quality control at the later stage. At the same time,we retrospectively analyzed the quality control results of the quarterly cancer chemotherapy medical records in our hospital during the above time period,and compared the quality control results of the medical records before and after the improvement. Results:The top 4 tumors in the chemotherapy medical record in our hospital were:lung malignant tumor,breast malignant tumor,esophageal malignant tumor and cervical malignant tumor. After the improvement,the average scores of tumor chemotherapy medical records in each department were improved compared with those before the improvement,and the differences were statistically significant(all P < 0.05). After improvement,the perfection rate of pathological diagnosis,tumor staging,chemotherapy indications,rationality of chemotherapy plan,title of chemotherapy plan maker,choice and dosage of chemotherapy drugs,record height,weight and body surface area,calculate drug dosage according to body surface area or AUC,and use of chemotherapy drugs(including pretreatment plan),adverse reaction monitoring,adverse reaction treatment,chemotherapy observation form,curative effect evaluation(≥2 cycles)and chemotherapy informed consent form were all higher than those before improvement,and the difference were statistically significant(All P < 0.05).Conclusions:By formulating tumor chemotherapy standards,strengthening the training of doctors,improving the pre-chemotherapy summary template and holding tumor chemotherapy seminars,our hospital has made the chemotherapy process more standardized,improved the quality of tumor chemotherapy,and ensured patient safety.