应用加权秩和比进行病历质量评价的实践与探讨

Exploration of Quality Evaluation of Medical Record Based on Weighted Rank Sum Ratio

目的 应用加权秩和比法对某医院各临床科室病历质量进行综合分析和评价,提高病历管理质控水平,为绩效考评提供依据。方法 以某院2019年住院病历为研究对象,选择病历超时限、病历按时归档率、丙级病历数及终末病历抽查得分四个反映病历质量的指标,应用加权秩和比法(WRSR)对16个内科学科、22个外科学科进行评价。结果 根据回归方程计算WRSR估计值,将病历质量分为上中下3档。结论 基于多指标、多维度的秩和比法可以综合评价病历质量,指出科室病历质控的重点工作方向,为医院绩效考核提供科学依据。

Objective To conduct comprehensive analysis and evaluation of the quality of medical records in clinical departments of a hospital by using weighted rank sum ratio(WRSR) method,so as to improve the quality control level of medical records and to provide reference for performance assessment.Methods The inpatient medical records of a hospital in 2019 were selected as the research objects.Four indexes reflecting the quality of medical records were selected,including medical record out of time,the rate of timely documentation of medical records,the number of grade C medical records and the score of spot check of final medical records.WRSR was used to evaluate 16 internal medicine disciplines and 22 surgery disciplines.Results WRSR was calculated by regression equation,and the quality of medical records was divided into three grades:upper,middle and lower.Conclusion WRSR based on multiple indexes and dimensions can comprehensively evaluate the quality of medical records,point out the key work direction of medical records quality control,and provide scientific basis for the performance assessment of the hospital.