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运行病历的管理与医疗质量 被引量:8

The Quality Management of Running Medical Records and the Quality of Medical Care
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摘要 目的对运行病历实时监控,以利提高医疗质量、防范医疗纠纷。方法自2008年起质控科不断加强运行病历质量监控力度,随机抽查科室运行危重疑难病历。由2008年每周一次增加到2009年每周两次。2008年共抽查2400份,2009年共抽查4800份,并分析2008年和2009年运行病历质量。结果 2008年有缺陷病历202份,缺陷率8.42%,2009年有缺陷病历100份,缺陷率2.08%,经卡方检验,P〈0.01,统计学有明显差异,表明2009年有缺陷病历的发生率明显减少。病历缺陷项目2009年517个,2008年601个,病历缺陷项目也明显减少。结论加强运行病历质量监控,及时发现问题及时整改,不仅能有效地减少病历书写缺陷,更重要的是提高了医疗质量,保证了医疗安全。 Objective To strengthen quality management of running medical records by real-time monitoring.So can improve the quality of care and prevent medical disputes.Methods Quality control department continue to strengthen running medical records quality control since 2008.Check the critical difficult medical records at random once a week in 2008 increased to twice a week in 2009.Check running medical records a total sample of 2,400 in 2008,and 4,800 in 2009,and analyze the quality of running medical records.Results There were 202 defective medical records in 2008,and the defect rate is 8.42%,100 defective medical records in 2009,and the defect rate is2.08%. There were statistics significant difference after Chi-square test,P〈0.01.The defective medical records has significantly reduced since 2009.Conclusion To strengthen quality control of running medical records,find the problems timely and correct them timely,can reduce defects of medical records effectively,what's more can improve the medical care quality and ensure the medical care safety.
作者 郑艳平 李曙光 唐峰 石彩霞 Zheng Yanping,LiShu guang,Tang Feng,Shi Caixia(Quality Control Department of Fourth Hospital of Changsha,Changsha 410006,Hunan Province, China )
出处 《中国病案》 2011年第4期 20-22,共3页 Chinese Medical Record
关键词 医疗质量 运行病历 监控 缺陷 Quality of medical care Running medical records Monitoring Defect
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