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目的了解医院病案质量现状,探索提高病案质量的办法。方法选取山东省某二甲医院2014年2月~8月院级质控的407份终末病案评价结果,运用统计图表等展示该院病案质量水平,找出病案质量薄弱环节,改进病案质量。结果 2014年2月~8月,该院甲级病案318份(78.13%)、非甲级病案89份(21.87%);89份非甲级病案中手术系列科室69份(占77.53%),因单项否决因素导致的51份(占57.30%)等。病案质量整体没有明显改进效果,该院病案质控体系、培训等系统存在严重缺陷。但单项否决情形逐渐减少,病案质控工作取得阶段性成效,在提高病案质量的方法、途径方面有新的启发。结论建立健全院科两级病案质控体系,运用“品管圈”等质量管理工具,消除病案质量系统存在缺陷,按专题有序推进,提高病案质量。
Objective To understand the status quo of medical records in hospitals and to explore ways to improve the quality of medical records. Methods A total of 407 final medical records of hospitalized hospitals in Shandong Province from February 2014 to August 2014 were selected to evaluate the quality of the medical records of the hospital by using statistical charts and so on. The quality of medical records was found to be weak and the quality of medical records was improved. Results A total of 318 cases (78.13%) of Grade A and 89 cases (21.87%) were non-Class A cases in the hospital from February to August 2014, and 69 cases (77.53%) of 89 cases of Non-Class A cases, 51 (57.30%) due to single negative factors. The overall quality of medical records did not significantly improve the results of the hospital medical record quality control system, training and other systems there are serious flaws. However, the single denial situation gradually decreased, and the quality control of medical records was achieved in a phased manner. There was a new inspiration in ways and means of improving medical record quality. Conclusion The establishment of quality control system for both hospital and hospital records and the use of quality management tools such as Quality Control Circle to eliminate the quality of medical record system have been put forward in an orderly way to improve the quality of medical record.