中国病案
中國病案
중국병안
CHINESE MEDICAL RECORD
2013年
5期
16-18
,共3页
心内科%病历%改进%策略%效果
心內科%病歷%改進%策略%效果
심내과%병력%개진%책략%효과
Department of cardiology%Medical records%Improvement%Strategy%Effect
目的实践持续性改进策略,提高心内科运行病历质量.方法随机抽查2012年1月-3月400份运行病历为对照组,2012年7月-9月400份运行病历为观察组,综合采用培训、考核、抽查、监督、奖惩等方式,对运行病历质量持续性改进3个月,比较整改前后的运行病历质量.结果对照组与观察组单项否决病历份数分别为5份(1.3%)和1份(0.3%),甲级病历数分别为330份(82.5%)和385份(96.3%),乙级病历数分别为56份(14.0%)和12份(3.0%),丙级病历14份(3.5%)和3份(0.8%),差异均具有统计学意义( P均<0.01).对照组与观察组病历平均分分别为(86.3±6.8)分和(95.9±3.1)分,差异具有统计学意义( P<0.01).结论综合采用培训、考核、抽查、监督、奖惩等方式对心内科运行病历进行持续性改进,可显著提高病历质量.
目的實踐持續性改進策略,提高心內科運行病歷質量.方法隨機抽查2012年1月-3月400份運行病歷為對照組,2012年7月-9月400份運行病歷為觀察組,綜閤採用培訓、攷覈、抽查、鑑督、獎懲等方式,對運行病歷質量持續性改進3箇月,比較整改前後的運行病歷質量.結果對照組與觀察組單項否決病歷份數分彆為5份(1.3%)和1份(0.3%),甲級病歷數分彆為330份(82.5%)和385份(96.3%),乙級病歷數分彆為56份(14.0%)和12份(3.0%),丙級病歷14份(3.5%)和3份(0.8%),差異均具有統計學意義( P均<0.01).對照組與觀察組病歷平均分分彆為(86.3±6.8)分和(95.9±3.1)分,差異具有統計學意義( P<0.01).結論綜閤採用培訓、攷覈、抽查、鑑督、獎懲等方式對心內科運行病歷進行持續性改進,可顯著提高病歷質量.
목적실천지속성개진책략,제고심내과운행병력질량.방법수궤추사2012년1월-3월400빈운행병력위대조조,2012년7월-9월400빈운행병력위관찰조,종합채용배훈、고핵、추사、감독、장징등방식,대운행병력질량지속성개진3개월,비교정개전후적운행병력질량.결과대조조여관찰조단항부결병력빈수분별위5빈(1.3%)화1빈(0.3%),갑급병력수분별위330빈(82.5%)화385빈(96.3%),을급병력수분별위56빈(14.0%)화12빈(3.0%),병급병력14빈(3.5%)화3빈(0.8%),차이균구유통계학의의( P균<0.01).대조조여관찰조병력평균분분별위(86.3±6.8)분화(95.9±3.1)분,차이구유통계학의의( P<0.01).결론종합채용배훈、고핵、추사、감독、장징등방식대심내과운행병력진행지속성개진,가현저제고병력질량.
@@@@Objective To practice continuous improvement strategies ,and improve the cardiology medical record quality .Methods A total of 400 running records from January 2012 to march 2012 were randomly inspected as control group .A total of 400 running records from July 2012 to September 2012 were randomly inspected as the observation group .Some methods such as training ,assessment , examination and supervision , rewards and punishments had been taken to improve medical record quality for 3 months .Comparing the quality of medical records before and after improvement . Results The number of single veto medical records of control group and observation group were respectively 5 (1 .3% ) and 1 (0 .3% ) .The number of class A medical records were respectively 330 (82 .5% ) and 385 (96 .3% ) .The number of class B medical records were respectively 56 (14 .0% ) and 12 (3 .0% ) .The number of class C medical records were respectively 14 (3 .5% ) and 3 copies (0 .8% ) .The differences are significant ( P<0 .01) . Conclusion The methods of training ,assessment , examination and supervision , rewards and punishments can significantly improve the quality of medical records .
