摘要
目的对某三甲医院病案内涵质量监控开展前后的病案质量进行检查,为提高住院病案质量提供可靠管理依据.方法调取某三甲医院2019年1月1日-2019年9月30日期间住院病案,每月每科请专家检查前一个月出院的10份病案,并将评价结果记录在评价表中.本研究共收到2446份为有效的评价表,通过克朗巴哈系数和半分系数检验量表的内部一致性信度和重测信度,分类汇总病案内涵质量存在问题.结果问卷克朗巴哈系数为0.920,半分系数为0.932,说明评价表填写的可信度高.经过9个月的检查工作,全院病案的优秀率从54.90%提高到了62.31%,中差率从1.50%下降到了1.10%.上级医师分析欠全面和病案拷贝问题是目前病案内涵质量存在的主要问题,分别占全部问题的17.76%和12.26%.病案拷贝问题中,其他拷贝问题等(包括拷贝错误)及主治医师查房与拟诊讨论完全相同这两项是主要的拷贝问题,合计占比为70.7%.内科与外科相比,在入院记录无家长签字、专科检查前后矛盾、三方有空项及用药填写方面,错误率有统计学差异.结论病案内涵质量检查工作可有效提高病案质量.
Objective The quality of medical records before and after the connotation quality control of medical records in a third-class hospital was examined in order to provide reliable management basis for improving the quality of medical records in hospital.Methods Each subject is asked to check 10 medical records discharged from the previous month,and the medical records management department regularly gives feedback on the problems in each department from January 1,2019 to September 30,2019.A total of 2446 effective evaluation forms were received,and the internal consistency reliability and test-retest reliability of the scale were tested by cronbach coefficient and half—score coefficient,and the problems in the connotation and quality of medical records were classified and summarized.Results The cronbach coefficient of the questionnaire is 0.920,and the half-point coefficient is 0.932,indicating that the evaluation form is highly reliable.After 9 months of inspection,the excellent rate of the hospital's medical records increased from 54.90%to 62.31%,and the rate of medium difference dropped from 1.50%to 1.10%.The lack of comprehensive analysis by superior physicians and the copy problems of medical records are the main problems in the quality of medical records at present,17.76%and 12.26%respectively.Among the copy problems of medical records,other copy problems(including copy errors)and the attending doctor's rounds are exactly the same as the planned consultations are the main copy problems,accounting for 70.7%of the total.Compared with surgery,there is a statistical difference in the error rate between internal medicine and surgery in terms of admission records without parental signature,contradiction before and after specialist examination,empty items in the three parties and filling in medication.Conclusion The quality check of medical records can effectively improve the quality of medical records.
作者
宋菲
曾跃萍
吕亚奇
刘颖
李莹
ong Fei;Zeng Yueping;Lv Yaqi;Liu Ying;Li Ying(Beijing Children's Hospital,Capital Medical University,Beijing 100045,China Corresponding author ZengYueping)
出处
《中国病案》
2021年第6期3-5,共3页
Chinese Medical Record
关键词
病案
内涵质量
质控
Medical records
Connotative quality
Quality control
