某院15440份终末病案质量分析

Quality Analysis of 15,440 Terminal Medical Records in a Hospital

目的 为了提高病案的完整性和准确性,进而提升病案质量,分析终末病案的主要缺陷及原因,为制定行之有效的整改措施提供参考依据。方法 逐份检查2021年4月16日-2021年10月15日病案15 440份,运用Microsoft Office Excel 2016版本对病案缺陷情况进行分类汇总与统计。结果 15 440份终末病案,存在缺陷的病案1325份,缺陷率8.58%。缺陷病案中甲级病案600份,占比45.28%;不合栺病案725份,占比54.72%。乙级病案348份,占比26.26%;丙级病案377份,占比28.45%。甲级病案中病案首页缺陷项目最多,其中质控时间填写错误188份,占比14.19%,乙级病案中,缺陷份数排在第1位的是有会诊医嘱漏会诊单293份。丙级病案缺陷内容主要是漏打印病程记录101份,占比7.62%。缺陷前5位的主要是病案不完整719份,占54.26%;日期填写错误216份,占16.3%;漏签字132份,占9.96%等。结论 终末存在缺陷的病案中不合栺病案占比较高,主要原因集中在项目填写不全、填写错误和缺项,漏签字,病案不完整、漏打印,漏重要的检查化验单等。需加强病历书写管理,注意病历的完整性和准确性的检查质控,同时应加强培训,提升临床医师的责任心和法律意识,最终提高病案的终末质量。

Objectives In order to improve the integrity and accuracy of the medical records and the quality of the medical records,the main defects and causes of the final medical records were analyzed.Methods The 15,440 medical records discharged from April 16th to October 15th in 2021 were examined one by one,and quality control analysis of the final medical records was conducted.Use the Excel 2016 edition to carry on the classification summary and the statistics to the medical record flaw situation,the statistical analysis medical record flaw situation.Results There were 15440 terminal medical records,among which 1325 had defects,with a defect rate of 8.58%.Among the defect cases,there were 600 grade-A cases,accounting for 45.28%;There were 725 unqualified medical records,accounting for 54.72%.There were 348 cases of Class B,accounting for 26.26%;There were 377 cases of class C disease,accounting for 28.45%.Among Grade-A medical records,the front page of medical records had the most defects,among which 188 were wrong in the filling of quality control time,accounting for 14.19%.Among Grade-B medical records,the number of defects ranked the first place was 293 consultation sheets with missing consultation orders.The main defect of Class C medical records was missing 101 copies of course records,accounting for 7.62%.Among the top 5 defects,719 medical records were incomplete,accounting for 54.26%.216 dates were filled in incorrectly,accounting for 16.3%;Missing signature 132,accounting for 9.96%, etc.Conclusions Among the medical records with defects at the end, the unqualified medical recordsaccounted for a higher proportion, and the main reasons were the incomplete filling of items, the mistakes in fillingin and the missing items, the omission of signatures, the incomplete medical records, the omission of printing andthe omission of important examination and test sheets, etc. It is necessary to strengthen the management of medicalrecords, pay attention to the quality control of the integrity and accuracy of medical records, and strengthen thetraining to enhance the sense of responsibility and legal awareness of clinical doctors, so as to improve the finalquality of medical records.