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目的探讨住院医师参与病案检查对其书写的病案质量的影响。方法按是否参与病案检查将研究对象分为实验组和对照组。比较实验组参与病案检查前后的病案优秀率,分别比较实验组和对照组2014年度和2015年度的病案优秀率,利用EXCEL整理数据,并应用统计软件SPSS19.0对病案优秀率进行卡方检验。结果实验组2015年度的病案优秀率明显高于2014年度(P<0.001);2015年度,实验组的病案优秀率明显高于对照组(P<0.001)。结论住院医师参与病案检查可显著改进其书写的病案质量。
Objective To investigate the impact of residents’ participation in medical record examination on the medical record quality. Methods According to whether to participate in medical record examination, the subjects were divided into experimental group and control group. The excellent rate of medical record in the experimental group before and after the medical record examination was compared. The excellent rate of the medical record in 2014 and 2015 in the experimental group and the control group were compared respectively. The data were sorted out with EXCEL. The excellent rate of the medical record was analyzed by chi-square test using the statistical software SPSS19.0. Results In 2015, the excellent rate of medical record in experimental group was significantly higher than that in 2014 (P <0.001). In 2015, the excellent rate of medical record in experimental group was significantly higher than that in control group (P <0.001). Conclusion Residents’ participation in medical record examination can significantly improve the quality of the medical records they write.