CAJ | 학술논문

目的：探讨病历缺陷档案在病案质量管理中的应用效果，为其他医院更好地进行病案质控提供借鉴。方法自2012年起，我院利用Excel2007，并根据《广东省病历书写与管理规范》中的住院病历评分标准为每位管床医生建立病历缺陷档案，对于每次抽查到的病历缺陷项目对应相应科室医生分别进行录入，同时将缺陷项目及时反馈主管医生本人，及时整改，对于屡次出现，且不改正的医生给予院级公示，并进行相应扣罚。实施1年后，对比前后全院病历质量改进情况。结果在为每位管床医生建立病历缺陷档案1年后，2012年全院甲级病案率达97．75％，高于2011年，差别具有统计学意义（P＜0．05）。特别是在地址填写不详、首页空项、漏诊/鉴别诊断混乱、既往/现病史描述不准确、病程记录无内涵、缺必要辅助检查及抗菌药物使用无指征等项目方面缺陷率较之前均有不同程度降低（P＜0．05），且缺陷率随着时间的延长呈现逐步下降趋势（P＜0．05）。结论为临床医生建立病历缺陷档案可以及时监控全院各临床医生病历缺陷情况，及时反馈，及时整改，并对改进科室病历质量具有显著效果。
목적：탐토병력결함당안재병안질량관리중적응용효과，위기타의원경호지진행병안질공제공차감。방법자2012년기，아원이용Excel2007，병근거《광동성병역서사여관리규범》중적주원병력평분표준위매위관상의생건립병력결함당안，대우매차추사도적병력결함항목대응상응과실의생분별진행록입，동시장결함항목급시반궤주관의생본인，급시정개，대우루차출현，차불개정적의생급여원급공시，병진행상응구벌。실시1년후，대비전후전원병력질량개진정황。결과재위매위관상의생건립병력결함당안1년후，2012년전원갑급병안솔체97．75％，고우2011년，차별구유통계학의의（P＜0．05）。특별시재지지전사불상、수혈공항、루진/감별진단혼란、기왕/현병사묘술불준학、병정기록무내함、결필요보조검사급항균약물사용무지정등항목방면결함솔교지전균유불동정도강저（P＜0．05），차결함솔수착시간적연장정현축보하강추세（P＜0．05）。결론위림상의생건립병력결함당안가이급시감공전원각림상의생병력결함정황，급시반궤，급시정개，병대개진과실병력질량구유현저효과。
Objective To explore the application effects of defective files of medical records in medical record quality management , and provide reference to managing medical records of other hospitals .Methods Since 2012 , with the use of Ex-cel, according to the grading standard of medical records in ″Guangdong medical writing and management practices″, defective files had been set up for every doctor in our hospital.The defective items of medical records and the corresponding doctors were recorded , and feedback was given timely for timely rectification .The doctor who made the mistakes frequently would be publi-cized in the hospital and would be fined accordingly.One year later, we would contrast the quality of medical records.Results Management methods results one year after defective files of medical records were set up for every doctor, The rate of grade A of medical records reached 97.75%in 2012 and was higher than the previous year, with the difference statistically significant (P<0.05).The rate of defects such as unknown addresses, empty entries in the first page, lack of diagnosis or differential diagnosis disorder, unclear past or current medical history, lack of connotation in progress notes, lack of necessary examinations and no in-dications for antimicrobial drug use were all lower than before (P<0.05), and defects rate decreased gradually over time.Con-clusion Defective files of medical records for clinicians can timely monitor the defects of medical records with timely feedback and timely rectification, and can improve the quality of medical records.