临床路径病案的质量分析

目的探讨临床路径病案质量控制的内容和方法。方法根据临床路径标准住院流程和治疗表单制定病案质控内容,对我院121例急性ST段抬高心肌梗死的病案进行临床路径质量分析。结果所查121份病案中,住院时间不符合路径标准最多,缺陷率为14.1%,入院诊断、诊断依据、检查项目、手术治疗时间、出院评估及变异因素缺陷率在4.1%～12.4%结论临床路径病案质控与临床路径规范实施密切相关,建立规范的临床路径病案质控体系及临床路径病案质控实施办法,将有助于临床路径工作开展。

Quality Analysis on Medical Records of Clinical Pathway

Objective To discuss the content and method of quality control for clinical pathway. Methods The items of quality control for medical records were established according to standardized clinical pathway of hospitalization process and treatment chart for acute ST-elevation myocardial infarction. Results The length of hospitalization time is the most inconformity to clinical pathway standard. Its defect rate is 14.1%. The defect rate of the admitting diagnosis, diagnostic evidence, inspection items, operation time, discharge evaluation and variation factors is between 4.1% to 12.4%. Conclusion The quality control of clinical pathway medical record is closely related to the standardization of clinical pathway implementation. It will be helpful to carry out clinical pathway through setting up a standardized medical record quality control system and measures.