质量管理在院前急救病案书写中的应用

Application of Quality Management in the Writing of Pre-hospital Emergency Medical Records

目的 探讨质量管理在院前急救病案书写中的应用以及对差错率和投诉率的影响,为提高院前急救病案质量提供指导。方法 某院急救中心2019年4月1日-2020年3月31日院前急救出车次数为9 600次,获得9 600份院前急救病案,随机抽取2019年4月1日-2019年9月30日的150份病案作为对照组,实施常规医务管理;2019年10月1日-2020年3月31日的150份病案作为实验组,实施PDCA循环管理。记录所有病案资料的缺陷项,包括一般项目、病史、诊断、急救记录、告知单签署情况、签名、电子化记录、交接记录等,管理结束时记录2组急救完成后2小时、3小时和6小时病案的电子归档率,记录所有病案差错率,主要包括:录入不合格、记录错误、内容丢失。比较质量管理前后患者投诉率及患者满意度情况。结果 实验组一般项目、病史、诊断、急救记录、告知单签署情况、签名、电子化记录、交接记录等病案缺陷项的发生率均低于对照组(P<0.05);实验组2小时、3小时、6小时病案归档率均高于对照组(P<0.05);实验组病案差错率低于对照组(P<0.05);实验组投诉率低于对照组(P<0.05),患者满意度高于对照组(P<0.05)。结论 质量管理可有效降低案缺陷项的发生率,提高2小时、3小时、6小时病案归档率,降低病案差错率和患者投诉率,提高患者满意度。

Objectives This study aims to explore the application of quality management in the writing of pre-hospital emergency medical records and its influence on the error rate and complaint rate and to provide guidance for improving the quality of pre-hospital emergency medical records. Methods From April 1, 2019 to March 31, 2020, the emergency center of a hospital made 9,600 pre-hospital emergency trips, and obtained 9,600pre-hospital emergency medical records. 150 medical records were randomly selected from April 1, 2019 to September 30, 2019 as a control group to implement routine medical management. 150 medical records from October 1, 2019 to March 31, 2020 were used as the experimental group to implement PDCA cycle management.This study recorded all the deficiencies of medical records, including general items, medical history, diagnosis,emergency records, signatures of notices, signatures, electronic records, handover records, etc., and record the electronic filing rate of medical records 2 hours, 3 hours and 6 hours after completion of first aid for 2 groups at the end of the administration. This investigation also recorded the error rate of all medical records, mainly including unqualified entry, record error, and content loss, and made a comparison of patient complaint rate and patient satisfaction before and after quality management.Results The incidence of defects in medical records, such as general items, medical history, diagnosis, emergency records, the signature of notices, signatures, electronic records, and handover records, in the experimental group was lower than those in the control group(P<0.05).The 2-hour, 3-hour, and 6-hour medical record filing rates in the experimental group were higher than those in the control group(P<0.05).The error rate of medical records in the experimental group was lower than that in the control group(P<0.05).The complaint rate of the experimental group is lower than that of the control group(P<0.05).Patients’ degree of satisfaction in the experimental group is higher than that in the control group(P<0.05).Conclusions Quality management can effectively reduce the incidence of case defects, increase the filing rate of 2-hour, 3-hour, and 6-hour medical records, reduce the error rate of medical records and the rate of patient complaints, and improve patient satisfaction.