医保病历书写质量缺陷与管理

Medical insurance medical record writing quality defects and management

目的分析医保病历书写质量缺陷及实施品管圈管理对病历书写质量的影响。方法选择某三甲医院2015年1月-2016年1月医保病历3 045份(品管圈实施前)和2016年12月-2017年12月医保病历3 080份(品管圈实施后),采用医院自制病历书写缺陷调查表分析病历缺陷情况,比较品管圈管理前后病历书写质量。结果实施品管圈管理后病历甲级率为81.89%高于管理前的72.38%,实施品管圈管理后病历缺陷率为14.56%低于管理前的20.69%,差异均有统计学意义(P<0.05)。品管圈管理前后医保病历书写缺陷的主要问题均为未按规定时间记录病程、三级查房内容雷同、主任医师首次查房无分析、次要诊断缺乏依据、用药指征记录不全等。结论在医保病历书写过程中采用品管圈管理可明显改善病历书写的完整性,提高病历书写质量。

Objective To analyze the quality defects of medical record writing and the effect of the campaign of quality control circle on the quality of medical record writing.Methods 3 045 medical insurance records from January 2015 to January 2016 and 3 080 medical insurance cases from December 2016 to December 2017 in a tertiary Hospital were selected,and the occurrence of medical record defects was analyzed by using self-made medical record writing defect questionnaires,the quality of medical records before and after management of quality control circles was compared.Results After the implementation of the quality control circle management,the rate of Grade A(81.89%) was higher than before the implementation(72.38%),the defect rate(14.56%)was lower than before the implementation(20.69%),the differences were statistically significant(P<0.05).The failure to record the course of the disease according to the prescribed time,the similarity of the three-level ward round,the first analysis of the first doctor′s room,the lack of basis for secondary diagnosis,and the incomplete records of medication indications were the main problems of medical insurance medical records before and after management.Conclusion In the course of medical record writing,the integrity of medical record writing can be significantly improved by using the management mode of quality control circle,so the quality of medical records has been greatly improved.