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2017-2021年特勤疗养档案缺陷分析及对策

Analysis on the Defects in Special Service Recuperation Files from 2017 to 2021
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摘要 目的分析特勤疗养档案缺陷,查找问题原因,探讨提升特勤疗案质量的举措。方法某疗养院质控部门由2名质控医师查阅2017年1月1日-2021年12月31日9219份特勤疗案资料,根据疗案书写管理规定及评分标准进行质控。应用χ^(2)检验分析主要缺陷类型及缺陷构成差异,总结缺陷原因。结果9219份特勤疗案中缺陷疗案共计1309份,前5项主要缺陷类型为疗案首页矫治效果错填127份,占9.70%;检查报告单填写不规范124份,占9.47%;疗程记录超时115份,占8.79%;疗程记录模式化111份,占8.48%;疗案首页新发生疾病错填103份,占7.87%。2017-2021年排在前5名的缺陷年度间比较,疗案首页矫治效果错填:P=0.046927;疗程记录超时:P=0.008787,P<0.05,差异具有统计学意义。检查报告单填写不规范:P=0.33838;疗程记录模式化:P=0.557788;疗案首页新发生疾病错填:P=0.966477,此3项比较,P>0.05,差异无统计学意义。结论特勤疗案主要缺陷中疗案首页矫治效果错填、疗程记录超时这2项缺陷呈现上升趋势,应从优化制度、宣教模式、环节质控、推动能力4个方面提升特勤疗案质量水平。 Objectives To analyze the defects of special service recuperation files,find out the causes of the problems,and discuss measures to improve the quality of treatment cases.Methods The quality control department reviewed 9219 special service medical records from January 1st,2017 to December 31st,2021,searched for problems and defects according to the medical record writing management regulations and scoring standards,and analyzed and summarized the types and causes of defects.Andχ^(2) test was used to analyze the annual composition differences of the main defect types(top five in order)from 2017 to 2021,then discussed and summarized the causes of defects.Results A total of the 9219 special service treatment cases,there were 1309 defective treatment cases in total,and the top five main defect types were 127 cases with incorrect correction effects on the front page(9.70%),124 cases with non-standard filling of the inspection report form(9.47%),115 cases with overtime treatment records(8.79%),111 cases with standardized treatment records(8.48%),and 103 cases with incorrect treatment effects on the front page(7.87%).According to the statistical comparison between groups,there was an overall upward trend in the treatment effect of the front page,the treatment course record was over time,and the two defects showed an overall upward trend over the past five years,while the other three items showed no significant improvement overall.Conclusions The main defects of special treatment cases were concentrated in incorrect filling of correction effects on the front page,non-standard filling of inspection report forms,timeout of treatment course records,modularization of treatment course records,incorrect filling of new diseases on the front page,and other aspects.Among them,the two defects of front page correction effect error filling and course record timeout were showing an upward trend.We should improve the quality level of special service medical cases from four aspects:optimizing the use of systems,changing the mode of propaganda and education,highlighting quality control of links,and promoting the improvement of capabilities.
作者 张舜 应英 范茂丹 陈华 潘安印 庞燕芬 周磊 Zhang Shun;Ying Ying;Fan Maodan;Chen Hua;Pan Anyin;Pang Yanfen;Zhou Lei(The Third Section of Air Force Hangzhou Special Service Recuperation Center,Hangzhou 310002,Zhejiang Province,China)
出处 《中国病案》 2023年第12期26-29,共4页 Chinese Medical Record
关键词 特勤疗案 医疗质量 环节质控 对策 Special service recuperation file Medical quality Link quality control Countermeasure
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