专项质量活动提升首次病程记录内涵质量

Effect of Special Quality Activities on Improving the Connotation Quality of the First Course Record

目的通过专项质量活动,探寻改善首次病程记录书写质量,提升医师临床思维能力的方法。方法成立专项活动小组,制定评价标准、查检表,统一工作流程,运用PDCA循环法连续开展6个月的整治活动,运用卡方统计比较整治前后的缺陷发生率。结果首次病程记录总缺陷率由76%,下降为49%,χ~2检验P直为0。其中,'病例特点未归纳提炼''诊断依据重点不突出''诊疗计划不具体'等缺陷率明显下降,分别由整改前的76%、34%、61%下降为整改后的46%、22%、49%。病例特点、诊断依据和诊疗计划三个模块的缺陷率整改前后对比,有统计学意义(P<0.05)。结论医师对病例特点等综合分析能力有明显提升。强化首次病程记录书写质量训练,可提高医师临床思维能力,改善病案内涵质量。

Objective To explore the methods of improving the quality of the first course record and writing and improving the clinical thinking ability of doctors through special quality activities.Methods A special activity group was set up,Develop evaluation standards,check list,and unify work process,and PDCA cycle was used to carry out 6 months of remediation activities.Results The first course recorded the total defect rate from 76%to 49%,and theχ~2 test P value was 0.Among them,the defect rate of'case characteristics not summarized and refined','diagnostic basis is not prominent'and'diagnosis and treatment plan is not specific'decreased significantly,from 76%,34%and 61%before the rectification to 46%,22%and 49%after the rectification respectively.The defect rates of the three modules of case characteristics,diagnostic basis and treatment plan were compared before and after rectification,and there were significant differences(P value was significantly less than 0.05).Conclusion The comprehensive analysis ability of doctors such as case characteristics was significantly improved.Improve the connotation quality of medical records.