摘要
目的探究层级管理对门诊电子病历质量的影响。方法门诊于2020年7月实行层级管理,选取2020年7—8月实行层级管理病历40份,命名为观察组;选取2020年6—7月未实行层级管理的就诊病历40份,为对照组。调查两组病历的书写质量(患者的主诉、病史、辅助检查、诊断、处理记录)、患者对病历使用的满意度以及患者复查率。结果观察组病历书写情况评分高于对照组(P<0.05);观察组患者的总满意率为90.00%,高于对照组的62.50%(P<0.05);观察组的复诊率也高于对照组(P<0.05)。结论层级管理可有效提高病历的书写质量,提高患者的满意度,提高复查率,管理效果显著,值得门诊管理中推广应用。
Objective To explore the influence of hierarchical management on the quality of outpatient electronic medical records.Methods The hierarchical management was implemented in outpatient clinics since July 2020.40 medical records were selected after the implementation of hierarchical management(from July to August 2020)(observation group),and another 40 medical records were selected before the implementation(from June to July 2020)(control group)for the study.The writing quality of the two groups(patient’s complaints,medical history,auxiliary examination,diagnosis,treatment records),patients’satisfaction with the use of medical records,and patient reexamination rate were investigated.Results The score for medical records writing of the observation group was higher than that of the control group(P<0.05).The total satisfaction rate of the observation group was 90.00%,higher than 62.50%of the control group(P<0.05),and the reexamination rate was also higher than that of the control group(P<0.05).Conclusion Hierarchical management can effectively improve the writing quality of medical records and patient satisfaction,and increase the reexamination rate,with significant management effect.
作者
王志强
袁利君
廖雪姣
余万其
肖万玲
张淑琴
阳靖
WANG Zhiqiang;YUAN Lijun;LIAO Xuejiao;YU Wanqi;XIAO Wanling;ZHANG Shuqin;YANG Jing(Outpatient Office,Shenzhen Third People's Hospital,Shenzhen Guangdong 518000,China;Chronic Disease Followup Department,Shenzhen Third People's Hospital,Shenzhen Guangdong 518000,China;Quality Control Department,Shenzhen Third People's Hospital,Shenzhen Guangdong 518000,China)
出处
《中国卫生标准管理》
2021年第12期15-18,共4页
China Health Standard Management
基金
龙岗区科技发展资金医疗卫生(扶持类)项目(20170405185608492)。
关键词
层级管理
门诊电子病历
病历书写质量
患者满意度
就诊效率
复诊率
hierarchical management
outpatient electronic medical records
writing quality of medical records
patient satisfaction
treatment efficiency
further consultation rate
