转变病案质控模式对病案质量的影响分析

Study on the Influence of Changing Medical Record Quality Control Mode on the Quality Management of Medical Records

目的比较病案质控模式由返聘退休专家督导改为在职医师质控,对比模式转变前后病案质量的变化,探讨提高病案质量的方法与措施。方法选取2017年3月-8月专家督导质控模式下质控的病案1001份作为对照组,2018年3月-8月在职医师质控模式下质控的病案1617份作为实验组,对比分析2组的甲级率、乙级率、丙级率以及质控病案数占出院总病案数比例有无改变。结果由专家督导质控模式改为在职医师质控模式后,甲级病案率从93. 81%上升至95. 98%,乙级病案率从5. 19%下降至3. 09%,审核病案数量占出院病案比例从1.94%上升至2. 85%,差别均具有统计学意义。结论在职医师参与度高的病案质控模式,有利于促进病案质量的提高。

Objective To investigate the changes in the quality and quantity of medical records before and after the change of the quality control model in a Three A and Tertiary Hospital in Jiangsu Province,and analyze the impact of the quality control model on the quality management of medical records.Methods From March 2018 to August 2018,a total of 1617 quality control medical records were taken as experimental group,and 1001 quality control medical records in the same period in 2017 before the change of quality control mode were taken as control group.The grade A rate,grade B rate,grade C rate and the proportion of medical records audited to the total number of discharged cases were compared between the two groups.Results Compared with the experimental group,the rate of Class A cases increased from 93.81%to 95.98%,the rate of Class B cases decreased from 5.19%to 3.09%,the rate of Class C cases decreased from 1.00%to 0.93%,The number of medical records reviewed increased from1.94%to 2.85%.The quality of medical records and the proportion of quality control medical records in the experimental group were significantly higher than those in the control group,and the difference was statistically significant.Conclusions Improving the quality control mode,increasing the participation of physicians,and improving the familiarity of the department on the writing requirements of medical records could make the quality of quality control of the overall medical records continue to rise.