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目的探索病案质量常态化管理模式及方法,质量持续良好状态,提升病案质量水平。方法建立多渠道,多层面的常态化病案质量反馈机制,贯穿病历质控的全过程,使环节质量与终末质量评价有机结合,回顾分析2015年下半年和2016年上半年住院病案,随机抽取医院不同科室出院归档的终末病案17474份,比较两组病案的甲级病案率和缺陷次数,同时回顾分析这两组病案在院时的超时次数、缺陷次数及医护质量扣分情况,来验证常态化病案质量反馈机制的应用效果。结果 2016年上半年甲级案率98.76%,明显高于2015年下半年的92.27%;而终末病案缺陷总次数261次,显著低于2015年下半年的470次。2016年上半年运行病历的超时次数、缺陷次数及医护质量扣分较2015年下半年均有减少。结论保证病案质量反馈机制的常态化和持久性,形成职能科室质控反馈—临床科室落实整改—职能科室跟踪评价的闭环管理,能够有效提升病案质量,促进医院总体医疗质量的提高。
Objective To explore the normalized management model and method of medical record quality, to keep the quality in good condition and to improve the medical record quality. Methods A multi-channel, multi-level, normalized medical record quality feedback mechanism was established. Throughout the whole process of medical record quality control, the link quality and terminal quality evaluation were organically integrated. The hospitalized medical records in the second half of 2015 and the first half of 2016 were retrospectively analyzed and randomly selected A total of 17474 medical records were discharged from different departments of the hospital. The number of Grade A cases and the number of defects were compared between the two groups. At the same time, the number of overtime, the number of defects and the quality of medical care in the two groups were retrospectively analyzed The application of normalized medical record quality feedback mechanism. Results In the first half of 2016, Grade A rate was 98.76%, significantly higher than the rate of 92.27% in the second half of 2015. The total number of final illness defects was 261, significantly lower than the 470 in the second half of 2015. In the first half of 2016, the number of overtime cases, the number of defects and the quality of service points had a decrease from the second half of 2015 respectively. Conclusion To ensure the normalization and persistence of the feedback mechanism of medical record quality, form the quality control feedback of functional departments - the closed-loop management of clinical departments to carry out the rectification and the follow-up evaluation of functional departments, which can effectively improve the medical record quality and promote the improvement of overall medical quality in hospitals.