火神山医院首次出院病案书写质量结果分析

目的对火神山医院出院病案质量检查结果进行分析,为COVID-19收容医院的医疗质量管理提供改进参考。方法收集火神山医院2020年2月4—24日290份出院病案,采用医院自制的《火神山医院病历书写质量检查评定表》对所有出院病案进行检查。对整体质量、条目质量、缺陷聚集特征等进行分析。结果290份病案平均得分为95.87±2.35分,甲级病案率为90.69%。普通病区与重症病区病案的等级分布差别显著(χ^2=85.62,P=0.000)。低于90分的病历27份,占9.31%,分布有一定的科室聚集性。要素检查整体合格率为80.44%±6.21%,内涵检查整体合格率为82.79%±13.52%,两部分合格率无显著性差别。病案检查主要扣分项目前几位分别为要素检查中的病历首页完整性和内涵检查的三级检诊制度落实、与家属沟通告知的相关记录,以及出入院诊断的规范性。医嘱记录、定期对患者病情分析评估与病程内容记录的个性化和准确性属于减分最少的几项。此次检查的290份病历中,未出现可推广借鉴的有益做法的相关记录。结论病案的完整性和准确性是COVID-19专病医院救治效果回顾性分析的重要依据,也是治疗技术后续研究的重要参考,对出院病案的阶段检查、深入分析病案质量指标能及时了解医疗过程中的不足,针对检出结果及时调整质量控制方法,是保证医院改进和提升医疗质量的重要手段。

Analysis on the Quality of Medical Record Writing in Huoshenshan Hospital

Objective To analyze the quality inspection results of the discharged medical records of Huoshenshan Hospital and to provide reference for medical quality management. Methods 290 discharged medical records of Huoshenshan Hospital from February 4, 2020 to February 24, 2020 were collected. The medical records were checked with the self-made "Huoshenshan Hospital Medical Record Writing Quality Inspection Evaluation Form". The overall quality, item quality and defect characteristics were analyzed. Results The average score of 290 cases was 95.87±2.35, and the overall excellent rate was 90.69%. There was a significant difference in the grade distribution of medical records between the General Ward and the Severe Ward(χ~2=85.62,P=0.000). There were 27 cases with score lower than 90,accounting for 9.31%, and the distribution had a certain degree of department aggregation.The overall qualification rate of element inspection was 80.44±6.21, and the overall qualification rate of connotation inspection was 82.79 ± 13.52. There was no significant difference between the two parts. The worst-performed items of the medical record examination were the integrity of the first page of the medical record in the element examination followed by the implementation of the three-level examination and treatment system of the connotation examination, the informed consent with the family members, and the standardization of the disease diagnosis. The individuation and accuracy of medical order record, regular analysis and evaluation of patients’ condition and course content record were the items performed best. There was no relevant record of beneficial practices that can be used for reference in the 290 medical records. Conclusion The integrate and accurate medical records is an important foundation forretrospective analysis of the treatment effect of Huoshenshan Hospital, as well as an important reference for follow-up study of treatment technology. Stage inspection and analysis of medical records quality can demonstrate the defi-ciencies in the medical process. Timely adjustment of quality control methods for the detection results can ensurethe high medical quality of the hospital.