全过程质控对提升某院住院手术病历质量的效果及影响因素探讨

Whole-process quality control improves the quality of surgical inpatient records:effcacy and infuencing factors

目的探讨环节联合终末的全过程质控对提升住院手术病历质量的影响。方法选取2022年1月-10月我院6000份住院手术病历作为研究对象,其中2022年1月-5月的3000份病历只采用自动质控进行病历管理,2022年6月起为实施全过程质控后收集的3000份病历,对比分析全过程质控前后住院手术病历书写及时性、重度缺陷发生率及病历质量评分。结果全过程质控后,住院病历书写及时性方面的不合格率、重度缺陷发生率均低于全过程质控前,差异有统计学意义(P<0.05),且住院病历质量评分甲级率明显提高,差异有统计学意义(P<0.05)。结论住院病历质量管理过程中将电子病历系统自动质控及人工环节质控运用于运行病历管理,终末质控运用于出院归档病历管理,两者结合的全过程质控对于提升住院手术病历质量,降低病历重度缺陷发生具有重要意义。

Objective To explore the impact of whole-process quality control(WPQC)on the quality of surgical inpatient records(SIRs).Methods A total of 6,000 SIRs generated during the period from January to October 2022 were selected,of which 3,000 were managed by automatic quality control only from January to May 2022(pre-WPQC group)and 3,000 underwent WPQC from June to October 2022(post-WPQC group).The timeliness,incidence of major defects,and record quality scores were compared between these two groups.Results The timeliness and incidence of major defects were significantly superior in the post-WPQC group than in the pre-WPQC group(all P<0.05).In addition,the post-WPQC group had significantly higher record quality score than the pre-WPQC group(P<0.05).Conclusions The application of WPQC,which incorporates the automatic quality control of electronic medical record system and the manual quality control links(including the final quality control for archived medical records after discharge),increases the quality of SIRs and reduces major defects in medical records.