论文部分内容阅读
目的研究医院手术科室病案书写质量改进措施的应用效果。方法选择2014年第一季度出院病例数量≥180例的手术科室,对所选的8个手术科室的病案缺陷问题进行分析。跟踪监控2014年第二季度至2015年第二季度所选的8个手术科室的病案缺陷率,采用卡方检验对实施改进措施后病案缺陷率的变化进行分析。结果通过参加手术科室早晨交接班和借助互联网进行信息反馈,对手术科室和部分医师进行个性化培训以及制定全院和科室的奖惩制度等措施,病案缺陷率由2014年第一季度的20.9%下降至第二季度的13.9%,随后略有上升,在2015年第二季度达到最低值12.4%。经卡方检验,差异均有统计学意义(P<0.05)。结论医院医疗质量管理部门应结合手术科室的医疗工作模式特点,有针对性地为科室制定简单有效的改进措施,不断提高手术科室的病案质量,以保障医疗安全。
Objective To study the application effect of quality improvement measures of medical records in surgical departments of hospitals. Methods A total of 180 cases of discharged patients in the first quarter of 2014 were selected as the surgical departments to analyze the medical record defects of the selected eight surgical departments. Tracking and monitoring of the two surgical departments selected from the second quarter of 2014 to the second quarter of 2015, the rate of medical record defects was analyzed. The chi-square test was used to analyze the change of the record rate after implementing the improvement measures. Results The rate of medical record defect decreased from 20.9% in the first quarter of 2014 to 20% in the first quarter of 2014 through participation in the handover of surgical departments in the morning and information feedback through the Internet, individualized training of surgical departments and some physicians, and the establishment of rewards and punishment systems in hospitals and departments. To 13.9% in the second quarter, then slightly increased, reaching a minimum of 12.4% in the second quarter of 2015. The chi-square test, the differences were statistically significant (P <0.05). Conclusion The hospital medical quality management department should combine with the characteristics of the medical operating mode of the operating department to make targeted and simple improvement measures for the departments and continuously improve the quality of medical records in the operating departments to ensure the medical safety.