【摘要】 目的探讨某医院三四级手术病案专项质控在病案管理中的应用价值,为进一步提高病案质量提高参考。方法以手术病案管理相关法律规章为指导,制定了本次考核评价标准,对2017年10月-2018年9月12483份三四级手术病案进行终末质量控制,比较质控前后期各项量化指标变化。结果质控前期总体缺陷率44.99%,质控后期缺陷率15.10%,缺陷率明显降低,差异具有统计学意义(X~2=762.95,P<0.01),同时质控后期术前讨论、手术安全核查表、术前小结、手术参与者一致性、授权委托书等缺陷率均明显降低,差异具有统计学意义(P<0.01)。结论持续进行专项质控,可进一步完善了病案质量管理制度,优化了病案质量质控流程,建立了奖惩并举机制。同时发挥了科主任的领导作用,逐渐强化临床医师病案责任意识,医疗质量得到持续改进。更多还原

【Abstract】 Objective To explore the application value of special medical records quality control in the quality management of medical records of the third and fourth class operation in a hospital for the further improvement of medical records quality. Methods According to the law and regulations issued by health administrative departments at all levels, the appraisal and evaluation standards are formulated. From October 2017 to September 2018, 12483 cases of The third and fourth class operation were subject to final quality control, and the changes of various assessment quantitative indexes before and after quality control were compared. Results The overall defect rate in the early stage of quality control was 44.99%, and that in the late stage of quality control was 15.10%. The defect rate was significantly reduced, and the difference was statistically significant(X~2=762.95, P<0.01). At the same time The preoperative discussion and so on was significantly reduced, and the difference was statistically significant(P<0.01). Conclusion Continuous special quality control can further improve the medical record quality management system, change the medical record quality control process, establish a reward and punishment mechanism and give play to the leading role of the department director, gradually strengthen the clinical physicians sense of responsibility for medical records, and the medical quality has been continuously improved.更多还原