环节质控对终末病历质量的影响

目的分析我院实施环节质控对终末病案质量的影响。方法将我院22个临床科室划分为内科、外科、妇产儿科和专科四个组,分别随机抽取实施环节质量监控前后的病历资料各200份,纵向比较平均甲级病历率、病历缺陷率、病历返修率及病历缺陷前5位数据的变化。结果相对于2007-2009年间的终末病历资料,2009-2011年实施环节质控后病历甲级病案率有显著提高,而病历缺陷率及病历返修率均呈现下降,并具有统计学意义(P<0.05);入院病历和病程记录中缺陷较前减少。结论实施环节病历监控对终末病案质量的提高有促进作用。

Impact of Three-level Quality Control in Link Medical Records on the Quality of Terminal Records

Objective To analyze the impact of three-level quality control in llnk medical records on the quality of terminal records in our hospital. Methods 22 clinical departments in our hospital were divided into four groups： Internal Medicine group, Surgical group, Obstetrics and Gynecology as well as Pediatrics group, the last was Specialist group. To select 200 medical records information before and after the implementation of three-level quality control in link medical records respectively and randomly, then make a verti- cal comparision on the variation of average Grade A medical record rate, medical records defect rate, medical records rework rate and the distribution of the top 5 medical records defect. Results Compared with the terminal medical records from 2007 to 2009, the rate of medical records Grade A in 2009 to 2011 improved significantly, with medical records defect rates and medical records repair rate decreased, it was of statistical significance（ P 〈 0.05）. The defects in medical records and progress notes also decreased compared with previous. Conclusion The implementation of three-level quality control in link medical records can promote the improvment of the quality of terminal records.