三级质控管理方法管理县级医院近三年病案首页质控医务人员工作水平的研究分析

Research on Level of Quality Control Medical Staff in County Hospitals Managed by Three-level Quality Control Management Method in Recent Three Years

目的通过三级质控管理方法管理县级医院病案管理人员,观察分析院内近三年病案首页质控情况,了解首页质控项目中所存在的缺陷以及缺陷产生原因,并提出改进对策措施。方法选取平邑县人民医院于2019年1月—2022年12月收集的302810份病案首页资料,实施三级质控管理方法,并选取2015年1月—2018年12月收集的301660份病案首页资料,实施传统质量控制管理方法,对比三级质控管理方法实施前后病案首页质控效果。结果三级质量质控管理方法实施后的病案首页信息、书写规范与原则、书写质量水平评分相较于实施前更高,差异有统计学意义(P均<0.05);三级质量控制管理方法实施后的病案首页编码正确率为99.99%,相较于实施前的99.89%更优,差异有统计学意义(χ^(2)=285.680,P<0.05)。结论基于信息系统的三级质控管理方法能够对医院病案首页质控水平提高提供支持,它在一定程度上降低了首页信息编码错误率,提高病案管理人员的病案首页质控质量评分水平。

Objective Through the three-level quality control management method,to observe the medical record management personnel of county-level hospitals and to analyze the quality control conditions of the first page of medical records in the hospital in the past three years,to understand the defects in the quality control items of the first page and the causes of defects,and to propose improvement measures.Methods The first page data of 302810 medical records collected from Pingyi County People's Hospital from January 2019 to December 2022 were selected to implement the three-level quality control management method.The first page resources of 301660 medical records collected from January 2015 to December 2018 were selected to implement traditional quality control management methods.The quality control effect of the first page of medical records before and after the implementation of the three-level quality control management method were compared.Results The scores of medical records first page information,writing norms and principles,and writing quality level after the implementation of the three-level quality control management method were better than those before the implementation,and the difference was statistically significant(all P<0.05).The accuracy rate of the first page code of medical records after the implementation of the three-level quality control management method was 99.99%,better than 99.89%before the implementation,and the difference was statistically significant(χ^(2)=285.680,P<0.05).Conclusion Three-level quality control management method based on information system can support the improvement of the quality control level of the first page of medical records in the hospital,which can reduce the error rate of the information code of the first page of medical records to a certain extent,and improve the quality score level of medical records management personnel.