某市35家医院住院病案首页填写质量分析及对策_王珊.pdf

中国病案2023 年第 24 卷第 2 期 17 理，并与医生的病历书写绩效挂钩。其次加强三级质控，明确职责。一级质控由科室质控医师负责，对病历内涵加强质控；二级质控由病案科负责，质控重点为出院记录，质控人员在质控过程中发现问题等可以通过实时发送弹窗消息的方式，反馈给当事医师，及时改正缺陷，对重复出现的问题及时反馈强调，避免问题重复出现；三级质控由质控科负责，质控专家对终末病案进行抽查质控。同时加强环节质控，及时干预缺陷的发生，从而提高出院记录质量4。3.2.3 加强培训 将新实施的山东省病历书写与管理基本规范(2020 年版)及电子病历应用管理规范作为医师培训的重要内容，针对出院记录书写缺陷内容进行专项培训，尤其将日间病历书写要求作为重点培训内容，直至医师掌握规范要求，病历书写的缺陷逐渐减少。医务部组织医务人员学习侵权责任法 医疗事故处理条例等法律法规，严格按照国家的规定书写病案，有效保证出院记录的书写质量，避免发生不必要的医疗纠纷。3.2.4 信息化利用 在电子病历系统质控功能中增加电子质控点，在经常出错的地方如出院日期、生命体征、视力、眼压、眼别等地方设置提醒功能，有缺陷时医生书写的出院记录不能完成保存，起到督促医师完成出院记录书写完整性的作用。为保证整本病案中前后数据一致，医师可以通过共享的信息化平台调用，既节约了书写病历的时间，又保证数据的完整性和准确性。参考文献 1 常艳群,王红艺.山东省病历书写与管理基本规范(2020年版)S.山东.山东科学技术岀版社,2020:127-134.2 陶春莲,徐新,陈丹霞英,等.提高出院记录书写质量的措施J.中国病案,2011,11(7):22-23.3 张喜雨,张晴晴,林炜炜.某眼科医院 2014 年出院患者疾病构成及帕累托图分析J.中国病案,2016,17(8):69-71.4 孙欣燕,孙冬梅,薛缪群,等.1647 份首次病程记录缺陷分析及对策J.中国病案,2019,20(5):11-13.5 刘晓明,阮鹤瑞.终末病案出院记录缺陷分析与改进对策J.中国病案,2015,16(8):21-24.6 宋菲,曾跃萍,吕亚奇,等.某眼科医院病案内涵质量存在的问题及改进措施J.中国病案,2021,22(6):3-5.7 俞宏彬,郑振佺,梁江萍,等.6827 份终末病案缺陷分析及改进措施J.中国病案,2018,19(12):16-20.8 王志娟,王美江,姜英姿,等.某眼科医院 2018 年 21096份病案质量分析J.中国病案,2019,20(11):3-5.9 孙珊梅,刘克新,杨翔宇,等.出院记录质量专项检查问题分析及对策J.中国病案,2012,13(8):12-13.(2022-02-10 收稿)某市 35 家医院住院病案首页填写质量分析及对策 王 珊 朱雨菲 李 强 余 唯 罗明春 摘要 目的 分析某市 35 家医院住院病案首页质量现状，找到存在的主要问题，提出改进措施,提高全市住院病案首页质量。方法 市病案质控中心组织市病案专业委员会专家组成员 40 名随机抽查某市公立医院22 家、民营医院 11 家，其中三级医院 10 家、二级医院 12 家、一级医院 2 家、未评级医院 2 家共计 840 份2021 年 1 月 1 日-2021 年 3 月 31 日期间的出院病案首页，并按照国家卫生健康委住院病案首页数据填写质量规范(暂行)住院病案首页数据质量管理与控制指标(2016 版)的要求进行检查评分，检查结果应用SPSS 17.0 软件进行统计分析，描述性分析用百分位数和构成比表示，采用 Kruskal-Wallis H 检验，以P0.05为差异有统计学意义。结果 840份住院病案首页平均得分为96.90分，中位数为97.50分，P25=95.50，P75=99。三级医院住院病案首页质量最高，二级医院次之(2=165.809，P=0.000)；妇幼保健院质量最高，综合医院次之，最差为康复医院(2=165.809，P=0.000)；营利性医院质量高于非营利性医院(2=44.858，P=0.000)。840 份抽检病案共发生缺陷频次 1394 次，其中患者基本信息 513 次(占 36.8%)、住院过程信息 117 次(占8.39%)、诊疗信息 493 次(占 35.37%)、三级医师质控签名 211 次(占 15.14%)、费用信息 60 次(占 4.30%)。结论 受病案信息系统、质控机制及规范掌握等因素影响，全市住院病案首页中前三位缺陷为患者基本信息、诊疗信息以及三级医师质控签名。不同级别医院缺陷分布有差异，三级医院患者基本信息缺陷最多，一级、二级及未评级医院在诊疗信息和三级医师质控签名方面的缺陷占比最高。关键词 住院病案首页；缺陷；质量分析；改进措施1 Quality Analysis and Countermeasures of Inpatient Medical Record Front Page Filling in 35 Hospitals in a CityQuality Analysis and Countermeasures of Inpatient Medical Record Front Page Filling in 35 Hospitals in a City Wang Shan,Zhu Yufei,Li Qiang,Yu Wei,Li Wei AbstractAbstract ObjectivesObjectives To analyze the current situation of the quality of the inpatient medical record homepage in 35 hospitals in a city,find out the main problems,and put forward improvement measures to improve the quality of the inpatient medical record front page in the city.MethodsMethods The municipal medical records quality control center organized 40 expert members of municipal medical records Professional Committee to randomly check the front pages of 840 discharged medical records from 22 public hospitals and 11 private hospitals in a city,including 10 tertiary hospitals,12 secondary hospitals,2 first-level hospitals and 2 unrated hospitals from January 1st,2021 to March 31st,2021.The inspection and score were performed according to the requirements of the National Health Commission Quality Specification for Filling in the Data of the Front Page of Inpatient Medical Records(Interim)and Data Quality Management and Control Index of the Front Page of Inpatient Medical Records(2016 edition).基金项目：四川省自贡市重点科技计划项目（2019ZC18）。自贡市第四人民医院(自贡市病案质控中心)，四川省，自贡市，643000 中国病案2023 年第 24 卷第 2 期 18 SPSS 17.0 software was used for statistical analysis of the inspection results,and the descriptive analysis was expressed by percentile and component ratio.Kruskal-Wallis H test was used,and P0.05 was considered statistically significant.ResultsResults The average score of the front page of 840 inpatient medical records was 96.90,the median score was 97.50,P25=95.50,P75=99.The quality of the front page of inpatient medical records in tertiary hospitals was the highest,followed by that in secondary hospitals(2=165.809,P=0.000).The quality of maternal and child health hospital was the highest,followed by general hospital,and the worst was rehabilitation hospital(2=165.809,P=0.000).The quality of for-profit hospitals was higher than that of non-profit hospitals(2=44.858,P=0.000).A total of 1394 defects occurred in 840 sample medical records,including 513 patients basic information(36.8%),117 patients hospitalization process information(8.39%),493 patients diagnosis and treatment information(35.37%),211 third-grade physicians quality control signatures(15.14%)and 60 patients cost information(4.30%).ConclusionsConclusions Under the influence of medical record information system,quality control mechanism and standard mastery,the top three defects in the front page of inpatient medical records in the city were basic patient information,diagnosis and treatment information and third-level physician quality control signature.There were differences in the distribution of defects among hospitals of different levels.The defects of basic information of patients in tertiary hospitals were the most common,and the defects