国际医药卫生导报
國際醫藥衛生導報
국제의약위생도보
INTERNATIONAL MEDICINE & HEALTH GUIDANCE NEWS
2013年
10期
1545-1548
,共4页
单项否决项目%病历质量%乙级病历%丙级病历
單項否決項目%病歷質量%乙級病歷%丙級病歷
단항부결항목%병력질량%을급병력%병급병력
Single-item rejection project%Quality of medical record%Grade B medical record%Grade C medical record
目的 通过对单项否决为乙级或丙级病历的项目进行分析,揭示病历质量中重大缺陷之所在,针对主要问题的原因,提出对策和建议.方法 抽查住院电子病历4858例,分为非手术科室和手术科室两组,两组之间非甲级病历率、缺陷出现率的差异性对比用x2检验.结果 手术科室的乙级病历率2.58％、丙级病历率0.99％,分别高于非手术科室的1.37％、0.04％；手术科室和非手术科室乙级项目最主要缺陷都是缺各类同意书或有效签名(缺陷出现率分别为1.31％和0.64％),以上差异有统计学意义；手术科室丙级项目主要集中在缺麻醉记录单(0.79％),其次是缺手术记录(0.16％).结论 只有各级医务人员、医院管理者对病历质量给予充分的重视,才能减少或杜绝重大缺陷项目,提高病历质量,保障医疗安全.
目的 通過對單項否決為乙級或丙級病歷的項目進行分析,揭示病歷質量中重大缺陷之所在,針對主要問題的原因,提齣對策和建議.方法 抽查住院電子病歷4858例,分為非手術科室和手術科室兩組,兩組之間非甲級病歷率、缺陷齣現率的差異性對比用x2檢驗.結果 手術科室的乙級病歷率2.58％、丙級病歷率0.99％,分彆高于非手術科室的1.37％、0.04％；手術科室和非手術科室乙級項目最主要缺陷都是缺各類同意書或有效籤名(缺陷齣現率分彆為1.31％和0.64％),以上差異有統計學意義；手術科室丙級項目主要集中在缺痳醉記錄單(0.79％),其次是缺手術記錄(0.16％).結論 隻有各級醫務人員、醫院管理者對病歷質量給予充分的重視,纔能減少或杜絕重大缺陷項目,提高病歷質量,保障醫療安全.
목적 통과대단항부결위을급혹병급병력적항목진행분석,게시병력질량중중대결함지소재,침대주요문제적원인,제출대책화건의.방법 추사주원전자병력4858례,분위비수술과실화수술과실량조,량조지간비갑급병력솔、결함출현솔적차이성대비용x2검험.결과 수술과실적을급병력솔2.58％、병급병력솔0.99％,분별고우비수술과실적1.37％、0.04％；수술과실화비수술과실을급항목최주요결함도시결각류동의서혹유효첨명(결함출현솔분별위1.31％화0.64％),이상차이유통계학의의；수술과실병급항목주요집중재결마취기록단(0.79％),기차시결수술기록(0.16％).결론 지유각급의무인원、의원관리자대병력질량급여충분적중시,재능감소혹두절중대결함항목,제고병력질량,보장의료안전.
Objective To carry out the analysis on the single-item rejection projects of grade B and grade C medical records,uncovering the reason for major defects of the quality of medical records,accordingly offering countermeasures and suggestions.Methods We inspected 4858 cases of electronic in-hospital medical record randomly,dividing them into non-surgical department and surgical department.Then checked the differences between two cases on the ratio of the non-A grade medical records and the occurrence rate of defects using x2 method.Results In surgical department,the ratio of grade B medical records was 2.58％,the ratio of grade C medical records was 0.99％,higher than those of grade B medical records and grade C medical records of non-surgical department which were 1.37％ and 0.04％ respectively.The most major defect of grade B projects in surgical department or non-surgical department was the lack of various kinds of letter of consent or valid signatures (the occurrence rate was 1.31％ and 0.64％ respectively).The above-mentioned differences were obvious.Grade C projects of surgical department were mainly focused on the lack of anesthesia notes (0.79％),next on the lack of surgery records (0.16％).Conclusion Only by fully paying attention to the quality of the medical record from different levels of medical staff and administrative staff of hospitals,can the major defects be reduced or prevented,the quality of the medical record is improved and the medical safety be ensured.
