医护一体化模式在骨科运行病历管理中的运用与效果评价

目的：探讨骨科医护一体化模式下运行病历管理方法，提高运行病历质量。方法：科室成立“医护一体化”运行病历专项管理小组，对科室运行病历质量现状及其原因进行分析，并根据原因制定相应对策。通过对科室随机抽查的运行病历质量状况进行实施前、后对照，比较医护一体化模式实施前3个月和实施后3个月的缺陷病历发生率、常见缺陷项目的发生率。结果：实施医护一体化运行病历管理后，缺陷病历发生率、常见缺陷项目发生率均较实施前有所下降，实施前后差异有统计学意义（P〈0．05）。结论：“医护一体化”运行病历专项管理小组的成立有助于提高运行病历质量，促进医护沟通，提高医疗质量并保障医疗安全。

The effect of doctor-nurse integration management model on medical records management in orthopedics ward

Objective： To explore the effects of doctor-nurse integration management model on medical records management in orthopedics ward. Methods： The doctor-nurse integration group was established to manage the medical records quality. They investigated the current status, problems and causes of medical records quality, and implemented the corresponding countermeasures to manage them. Then they checked the medical records quality using sample check method. Results： Three months later, both the defect rate of general medical records and common items in medical records were lower than before （P〈0.05）. Conclusion： The doctor-nurse integration group was helpful to improve medical records quality, promote communications between doctors and nurses, and ensure medical quality and care safety.