论文部分内容阅读
目的比较综合病历质量控制方法与单一病历质量控制方法在我院病案管理方面的控制效果，探索一种提高病区病历质量的质控方法。方法应用综合病历质量控制体系对病历进行质控，并随机抽取采用综合病历质量控制方法的观察组和单一病历质量控制方法的对照组进行分析。结果观察组与对照组在入院记录、上级医师首次查房录、抢救记录、交接班记录、转科记录、阶段小结以及死亡记录的完成情况无统计学差异，观察组在首次病程记录、病程记录、操作记录完成情况优于对照组。观察组病历专家打分分值高于对照组病历专家打分分值。观察组病历缺项情况与对照组病历缺项情况有统计学差异，观察组病历缺项情况低于对照组病历缺项情况。结论综合病历质量管理体系在病历质量控制方面具有独特优势，能够提高病历书写质量。“,”Objective To compare the comprehensive quality control records and records a single method of quality control in our hospital case management results, explore a medical ward improve quality. Methods Comprehensive medical quality control system for quality control of medical records, medical records and randomly integrated quality control system controls the observation group and a single method of quality control records were analyzed. Results The observation group and the control group in admission records, the higher the physician first rounds were recorded, rescue records, shift recording, turn Branch records, completion stage summary and death records no significant dif erence was observed in the course record 、progress notes for the first time and operating record completion than the control group. Medical expert scoring higher in the observation group medical expert scoring. Incomplete medical observation group and the control group medical conditions missing items were significantly dif erent circumstances, medical observation group than the control group cases missing items missing items medical conditions. Conclusion The comprehensive medical quality management system has a unique advantage in medical quality control, to improve the quality of medical records.