精细化管理对病案管理质量的影响

Impact of refined management on the quality of medical record management

目的 探讨精细化管理对病案管理质量的影响,以期为病案管理提供参考。方法 郑州大学附属郑州儿童医院2020年1—12月实施传统病案管理,随机选取这期间126例住院患儿的病案作为对照组。郑州大学附属郑州儿童医院2021年1—12月实施精细化病案管理,随机选取这期间126例住院患儿的病案作为观察组。对照组病案采用传统病案管理制度,观察组病案采用规范化病案管理。比较2组病案甲级病案率;比较2组病案不良事件发生情况;患儿出院3个月时,采用自制病案管理满意度调查问卷对患儿家属进行调查。结果 对照组病案中甲级病案97份,甲级病案率为76.98%。观察组病案中甲级病案115份,甲级病案率为91.27%。观察组甲级病案率高于对照组,差异有统计学意义(P<0.05)。观察组病案不良事件发生率低于对照组,差异有统计学意义(P<0.05)。观察组病案管理满意度评分为(26.52±2.34)分,高于对照组的(21.08±2.31)分,差异有统计学意义(P<0.05)。结论 精细化管理应用于医院病案管理中,有利于提升管理人员的岗位意识,提高病案管理质量与效果,降低病案不良事件的发生率,值得推广应用。

Objectives This study aimed to explore the impact of refined management on the quality of medical record management to provide evidence for medical record management.Methods Traditional medical record management was implemented at Children's Hospital Affiliated to Zhengzhou University from January to December 2020.A total of 126 medical records of children during this period were randomly selected as the control group.Normative medical record management was conducted from January to December 2021,and 126 medical records of children during this period were randomly selected as the observation group.The control group employed the traditional medical record management system,while the observation group adopted normative medical record management.The incidence of A-level medical records and adverse events in the two groups were compared.Furthermore,a self-made questionnaire was used to investigate family members of child satisfaction with medical record management three months after discharge.Results The control group had 97 A-level medical records,with an A-level medical record rate of 76.98%.The observation group had 115 A-level medical records,with an A-level medical record rate of 91.27%.The A-level medical record rate in the observation group was significantly higher than that in the control group(P<0.05).The incidence of adverse events in the observation group was significantly lower than that in the control group(P<0.05).The satisfaction score of medical record management in the observation group was significantly higher than that of the control group(26.52±2.34 vs.21.08±2.31;P<0.05).Conclusion The application of refined management in hospital medical record management is conducive to enhancing the job awareness of management personnel,improving the quality and effectiveness of medical record management,and reducing the incidence of adverse medical record events.These advantages hold promise for a wider application of this technique.