帕累托分析法在病历质量管理中的应用

Application of Pareto analysis in quality management of medical records

目的分析某医院病历质量存在的主要问题,找出产生问题的原因并提出改进措施。方法随机抽取某医院2019年1月1日至12月31日出院病历376份,运用帕累托原理统计分析病历质量的主要问题。结果病历检查问题涉及26项类别,其中医师签名、鉴别诊断、既往史、家族史、查房时限、疾病诊断、病例特点、上级医师查房和病情变化记录9项内容为主要问题,累计百分比为76.07%。结论从医务人员专业技术能力培训、科室质控体系建设、绩效考核、电子病历实时质控系统入手,切实解决病历书写存在的问题,提高病历质量。

Objective The article analyzes the main problems affecting the quality of the medical records,find the cause of the problem and proposes improvement measures.Methods A total of 376 rehabilitation department’s medical records were randomly selected from 2019,medical records were analyzed by Pareto’s principle.Results The medical record examination questions involve 19 categories.The main problems are the physician’s signature,differential diagnosis,past history,family history,ward round time limit,disease diagnosis,case characteristics,superior physician rounds and condition change records,and the cumulative percentage is 76.07%.Conclusion We should carry out medical training for doctors,implement a real-time quality control system for electronic medical records,strengthen the department quality control management,incorporate the quality of medical records into performance appraisal management,so as to solve the problem of medical records,Improve the quality of medical records.