医院评审中病案质量检查新模式探讨

为解决医院评审中病案抽检＂选择性偏倚＂、＂遗忘效应＂、评分标准差异和不同医院间可比性的问题,而专门优化病案质控流程,并专项研发相关的软件。将＂随机抽样＂和＂病案翻拍＂的联合应用,根据广东省《病历质量评分标准》,转换成计算机软件＂质控点＂程序模块进行打分。使每份病案都有相对公平的概率被抽中检查,从而构建了公平、快捷、完整的病案质量评审模式。通过本病案评审模式,不仅优化院内病案质控流程,而且覆盖区域性多家医院,促进病案质量的整体性提升,方便医疗行政和学术指导部门对病案质量的监测和指导。

A new mode exploration of medical record quality examination in hospital review

To optimize the process of medical record quality control specially,thus solving the problems of "selection bias","forgetting effect",differenciation in score criterion in medical record spot checking and the comparability among different hospitals,and investigating relevant software.According to the medical record quality score criterion in Guangdong province,combining "random sampling" and "medical record recopy",then converting into "quality control spot" program module to grade.Establishing a fair,convenient and complete medical record quality review mode to guarantee each medical record has the same chance to be chosen for inspecting.By this mode,not only optimizing the process of medical record quality control specially but also covering many regional hospitals,thereby promoting the integrity to enhance medical record and making convenience to the monitoring and guiding of medical administration as well as academic guidance department.