口腔专科医院终末病案质量的现状分析

Analysis of the Final Inpatient Medical Records in Peking University Hospital of Stomatology

目的回顾性分析北京某口腔专科医院终末病案质量问题,为提升病案质量提供依据。方法对医院在2017年11月1日-2018年10月31日出院的终末病案的质量进行形式质控,对各病区的缺陷率和缺陷类型进行描述性分析,对各病区、各医护人员类型在完成病案修改所需的时间上进行比较分析。结果在7507份终末病案中,缺陷病案共391份,缺陷率为5.21%;病案质量问题主要包括14种缺陷类型,共476个缺陷项,其中以缺少手术记录、缺少麻醉术前和术后访视单、缺少出院记录为主,这三类问题累计占60.30%;60.50%的缺陷项在0~7天内完成修改;病区及医护人员类型在完成病案修改所用时间的分布上均具有统计学意义。结论应通过建立奖惩机制,构建方便快捷的交流平台,加强质控体系的管理力度,完善电子病历管理系统等措施,促进病案质量的持续改进。

Objective This article aims to find out problems of the final inpatientmedical recordsquali tymanagement,and provide evidence for improvementof medical records quality.Method Descriptive analysis and comparisonanalysis were used to analyze the final inpatient medical records from Novemberl,2017 to October 31,2018,in Peking University Hospital of Stomatology.Results The defect rate of inpatient records was 6.34%.The main problems included operation records missing,visiting records missing before and after anesthesia,and discharge records missing,which accounted for 70.39%of the total.The distributions of time taken to revise the records had significant differences statistically in different inpatients area and among people with different responsibilities.Conclusion The quality of inpatient medical records could be improved by such measures as rewards and punishment system,constructing a convenient and fast communication platform,strengthening three-level quality control,and improving the electronics medical records management system.