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目的探讨构建病案质量控制体系,形成科学、系统的病案质量管理模式,全面提高病案质量,规范医疗行为,确保医疗安全。方法 2014年运用前馈控制的理论和方法,以国家卫生行政部门颁发的法律规章为指导,制定了医院病案质量评价标准,建立了三级质控组织,确定质量控制指标,并对全面实施质量控制体系前后的2013年1月-2013年3月、2014年1月-2014年3月各随机抽取的3000份住院病案的书写缺陷率、甲级病案率、出院病案3天回收率进行分析比较。结果通过病案质量控制体系的构建与实施,病案书写缺陷率由全面质量控制前的23.23%降至14.07%;甲级病案率由全面质量控制前的92.03%提高至95.87%;出院病案3天回收率由全面质量控制前的83.87%提高至95.07%。病案缺陷率、甲级病案率和病案3天回收率的差异均有统计学意义(P<0.01)。结论全面、系统的三级质量控制体系的构建与实施,能充分发挥各级病案质量管理组织的监管作用,增强医务人员规范书写病案的能力和自觉性,显著提高病案质量。
Objective To explore the construction of medical records quality control system and to form a scientific and systematic medical records quality management model to improve medical record quality, standardize medical behaviors and ensure medical safety. Methods In 2014, using the theory and method of feedforward control, guided by the laws and regulations promulgated by the national health administrative department, the hospital evaluated the medical record quality evaluation standard, established the third-level quality control organization, determined the quality control index, Control system before and after the January 2013 - March 2013, January 2014 - March 2014 randomly selected 3000 in-hospital records of writing defect rate, Grade A case-rate, discharge rate of 3 days were analyzed and compared . Results Through the construction and implementation of the medical record quality control system, the defect rate of medical record writing decreased from 23.23% before total quality control to 14.07%; the grade A medical record rate increased from 92.03% before the total quality control to 95.87%; the discharged medical record was recovered within 3 days The rate increased from 83.87% before total quality control to 95.07%. The differences of the rate of medical record defect, grade A record and 3-day record of medical record were all statistically significant (P <0.01). Conclusion The construction and implementation of a comprehensive and systematic three-level quality control system can give full play to the regulatory role of medical records quality management organizations at all levels, enhance the ability and consciousness of medical personnel to standardize the writing of medical records, and significantly improve the quality of medical records.