某三级专科医院2022年度细菌培养检查记录符合率调查分析

Analysis of the baseline investigation results of the conformity rate of bacterial culture examination records in a tertiary specialized hospital in 2022

目的通过对某三级专科医院细菌培养检查记录符合率基线进行调查分析,了解细菌培养检查病历书写现状,探讨提高细菌培养检查记录符合率的改进路径及相关措施。方法根据《病案管理质量控制指标(2021年版)》要求,对2022年度细菌培养检查的6317份病历进行回顾性分析。结果医嘱执行率为100.00%,报告单完整率100.00%,病程记录率81.05%,结果分析率为33.07%,细菌培养检查记录符合率为33.07%。结论进一步提高细菌培养检查记录符合率,提升病案内涵质量刻不容缓。

Objective This paper aims to investigate and analyze the baseline conformity rate of bacterial culture examination records in a tertiary specialized hospital.By doing this,this paper seeks to understand the current situation of medical record writing of bacterial culture examination and explore the improvement path and relevant measures for enhancing the conformity rate of bacterial culture examination records.Methods According to the requirements of“Quality Control Index of Medical Record Management(2021 Edition)”,a retrospective analysis was conducted on 6317 medical records that underwent bacterial culture examination in 2022.Results The execution rate of medical orders was 100.00%,the completeness rate of the report sheet was 100.00%,the record rate of medical records was 81.05%,the analysis rate of results was 33.07%,and the conformity rate of bacterial culture examination records was 33.07%.Conclusion It is imperative to enhance the conformity rate of bacterial culture examination records and improve the quality of medical records in terms of content.