四川省某市病案质量现状及对策

Analysis of the Quality and Solution of Medical Records in a City in Sichuan Province

目的分析某市出院病案书写质量和管理现状,发现存在的问题,提出相应的对策,为医院管理部门及其上级主管部门制定病案质量控制管理办法和措施提供参考。方法分别抽取市属及市注册36家医疗机构2019年1月1日-3月31日和2020年1月1日-3月31日合计418份出院病案,按照四川省病案质量评审标准条款,对病案进行质量检查,经统计和分析后作出质量评定。结果病案质量总体得分为87.49分,其中三级医院平均90.74分,二级医院平均85.33分,一级医院平均88.53分,三级医院的病案质量明显高于其他级别医院;公立医院平均88.45分,民营医院平均85.47分,公立医院病案质量明显高于民营医院;病案质量缺陷集中在住院病案首页缺陷(292例次)、入院记录缺陷(268例次)、病程记录缺陷(358例次)。缺陷主要特点是记录缺项、不全面;单否项缺陷中知情同意问题有14份病案,其次是抗菌药物使用不符合临床应用指南有9份病案,是单否缺陷的主要问题。结论某市病案质量缺陷问题与医疗机构的差异化受监督力度、改进、质控机制、重视程度等因素影响,应加强督导和培训、强化整改、完善质控机制、提高重视程度,切实提升病案质量。

Objectives This study aims to analyze the quality and management situation of outpatient medical records and find the existing problems so as to propose the corresponding countermeasures,which provide references for hospital management departments and their higher authority to determine solutions and measurements for medical record quality management.Methods 418 outpatient medial records from 36 municipal and urban-registered medical institutions were selected from January 1 through March 31,2019 and from January 1 to March 31,2020.All medical records went through quality inspection based on medical record quality review standard in Sichuan Province.Quality assessments were made after statistical analysis.Results The average score of medical record quality was 87.49,among which the average score of the tertiary hospitals was 90.74,that of the secondary hospitals was 85.33 and that of the first-class hospitals was 88.53.The medical record quality of tertiary hospitals was significantly higher than that of others.The average score of public hospitals was 88.45 and that of private hospitals was 85.47.The medical record quality of public hospitals was significantly higher than that of private hospitals.Medical record quality defects were mainly defects in the medical record front pages(292 cases),admission records(268 cases)and disease progression record(358 cases).The main characteristics of the defects were missing record terms and incompleteness.Informed consent form defect,which was involved in 14 medical cases,and improper use of antibiotics according to guidelines for clinical application of antibacterial drugs,which was involved in 9 cases,were the main problem of veto defect.Conclusions The medical record quality defects of the investigated city and the differentiation among medical institutions were impacted by the factors of the degrees of supervision,improvement,quality-control mechanisms and attention.Hospitals should focus on the supervision and training,strength rectification,improve the quality control mechanism and pay more attention to the existing problem,in order to practically enhance the medical record quality.