摘要
目的探究基于微信公众号的管理模式在妇产科住院患者病案管理中的应用,为提升妇产科病历书写质量提供一定的指导。方法选择2019年2月1日-2020年4月15日于某院应用微信公众号管理的妇产科住院患者病案112例纳入观察组,另选取2017年5月10日-2018年10月23日某院未应用微信公众号管理的妇产科住院患者病案95例纳入对照组。对两组病案质量进行比较;比较两组病历书写完整度及病案缺陷发生情况;比较医师对两种病案管理模式的满意度。结果观察组优秀病案占比91.07%高于对照组的74.47%,差异具有统计学意义,P<0.05;观察组病历书写完整度中,治疗目的项目完整度88.39%、适应症项目完整度82.14%、禁忌症项目完整度84.82%、入院病史项目完整度89.29%、治疗信息完整度87.50%,高于对照组的(74.74%、69.47%、70.53%、77.89%、75.79%),差异具有统计学意义,P<0.05;观察组病案缺陷中记录缺失率1.79%、不准确/不连贯率2.68%、冗杂重复率2.68%及病案缺陷总发生率8.04%低于对照组的(11.57%、9.47%、9.47%、34.74%),差异具有统计学意义,P<0.05;观察组医师病案管理服务满意度为92.31%,明显高于对照组的69.23%,差异具有统计学意义,P<0.05。结论利用基于微信公众号的管理模式对妇产科住院患者病案管理可提高病案记录质量,减少病案缺陷的产生,提升医师对病案管理的满意度,有良好的应用价值。
Objective To explore the application of management mode based on WeChat official account in medical records management of inpatients in obstetrics and gynecology department,so as to provide certain guidance for improving writing quality of obstetrics and gynecology medical records.Methods A total of 112 medical records from inpatients in obstetrics and gynecology department who underwent WeChat public account management in the hospital from February 1,2019 and April 152020 were included in observation group,while another 95 medical records from inpatients not undergoing the above management from May 102017 to October 232018 were included in control group.The quality of medical records,completeness of medical record writing,occurrence of medical records defects,and physicians’satisfaction with medical records management were compared between the two groups.Results The ratio of excellent medical records in observation group was significantly higher than that in control group(91.07%vs 74.47%)(P<0.05).The completeness rates of treatment purpose,indications,contraindications,hospital medical history and treatment information in observation group were 88.39%,82.14%,84.82%,89.29%and 87.50%,significantly higher than those in control group(74.74%,69.47%,70.53%,77.89%,75.79%)(P<0.05),the overall incidence rates of records defects,inaccuracy/incoherence,redundancy and repetition,and medical records defects in observation group were 1.79%,2.68%,2.68%and 8.04%,significantly lower than those in control group(11.57%,9.47%,9.47%,34.74%)(P<0.05).The satisfaction rate of physicians with medical records management service in observation group was significantly higher than that in control group(92.31%vs 69.23%)(P<0.05).Conclusion Application of management mode based on WeChat official account in medical records management of inpatients in obstetrics and gynecology department can improve the quality of medical records,reduce the occurrence of medical records defects,and increase physicians’satisfaction with medical record management,which is of good application value.
作者
杜美兰
徐声波
Du Meilan;Xu Shengbo(Xianning Hospital of Traditional Chinese Medicine,Xianning 063000,Hubei Province,China;不详)
出处
《中国病案》
2021年第10期7-9,共3页
Chinese Medical Record
关键词
微信公众号
妇产科
病案管理
WeChat official account
Obstetrics and gynecology department
Medical record management
