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目的制订环节病历时限性专项质控标准,应用于环节病历时限性专项检查中。方法根据《病历书写基本规范》,应用德尔菲专家咨询法制订环节病历时限性专项质控标准,并根据此项标准,依托信息化平台,应用电子病历质控系统对全院环节病历进行时限性专项检查。结果最终制订的环节病历时限性专项质控标准包涵4个一级指标和25个二级指标;依据该标准对2017年5月某院1000份环节病历进行时限性专项检查,按时完成的病历数为744份,总体合格率为74.4%,其中,入院记录、手术记录及出院记录的合格率均达到95%以上,而病程记录存在较大的时限性缺陷。结论制订的环节病历时限性专项质控标准具有较高的科学性和可靠性,可为环节病历质量控制提供科学依据,同时对于提高医院整体病案质量具有重要意义。
Objective To formulate a time-limited special quality control standard for medical records, and to apply it to the time-limited special examination of medical records. Methods According to the Basic Medical Records Writing Standard, the Delphi medical expert consultative law was used to establish the time-limited special quality control standard of the medical history records. Based on this standard and based on the informatization platform, the electronic medical record quality control system was used to carry out the time- Special inspection. The results of the final formulation of the medical records time limit of the special quality control standards include four first-level indicators and 25 second-level indicators; based on the standard for a hospital in May 2017 a record time-specific medical records 1000 cases, completed on time medical records For the 744 copies, the overall pass rate was 74.4%, of which, admission records, surgical records and discharge records of the pass rate of more than 95%, while the duration of the record there is a large time-limited defects. Conclusion It is scientific and reliable to formulate the time-limited special quality control standard of medical records and provide a scientific basis for the quality control of medical records of the link. Meanwhile, it is of great significance to improve the quality of medical records of hospitals as a whole.