CAJ | 학술논문

目的通过对终末病历病案质量的评价分析,研究实施临床路径对病历病案质量影响.方法选择2010年8月至2012年8月实施临床路径管理的病例1436例作为观察组,随机选择同时期未实施临床路径的病例1430例作为对照组.所有病历均经病历质量专家小组评审并确定甲级、乙级、丙级;记录“单项否决项”和“单项扣分5分”的病历数及核查出院病历3日归档率、病案首页完整规范率和病历完整性.结果观察组终末病历的甲级率比对照组明显提高,乙级和丙级率比对照组明显降低( P<0.001);观察组“单项否决”和“单项扣分5分”的发生率低于对照组( P<0.05);观察组出院病历3日归档率、病案首页填写完整规范率和病历完整性高于对照组( P<0.05).结论实施临床路径不仅对提高医疗质量和保障医疗安全有重要作用,而且有助于提高病案质量和完善病案管理.
목적통과대종말병력병안질량적평개분석,연구실시림상로경대병력병안질량영향.방법선택2010년8월지2012년8월실시림상로경관리적병례1436례작위관찰조,수궤선택동시기미실시림상로경적병례1430례작위대조조.소유병력균경병력질량전가소조평심병학정갑급、을급、병급;기록“단항부결항”화“단항구분5분”적병력수급핵사출원병력3일귀당솔、병안수혈완정규범솔화병력완정성.결과관찰조종말병력적갑급솔비대조조명현제고,을급화병급솔비대조조명현강저( P<0.001);관찰조“단항부결”화“단항구분5분”적발생솔저우대조조( P<0.05);관찰조출원병력3일귀당솔、병안수혈전사완정규범솔화병력완정성고우대조조( P<0.05).결론실시림상로경불부대제고의료질량화보장의료안전유중요작용,이차유조우제고병안질량화완선병안관리.
@@@@Objective To study the effect of the implementation of clinical pathway on quality of medical records through evaluating and analyzing quality of terminal medical records .Methods A total of 1436 patients who were treated by clinical path procedure ,were selected as observation group from August 2010 to August 2012 .A total of 1430 cases without introducing clinical pathway at the same time were randomly selected as the control group .According to regulations of the Ministry of Health ,al medical records were reviewed by the experts ,and three grades of A ,B and C were determined ;recording the “line item veto” and “individual y subtracting 5 points” ;inspecting filing rate of discharged within three days ,completing standard of the front page of medical records ,and the integrity of medical records .Results The rates of grade A in the observation group were much stronger than that of control group ,while the rates of grade B and C were significantly lower than those of control group ( P<0 .001);“ The line item veto” and“the individual y subtracting 5 points ” in observation group were lower than those of the control group ( P< 0 .05);The filing rates of discharged medical records within three days ,completing standard to the front page of medical records and the integrity of medical records in the observation group were higher than that of the control group ( P<0 .05) .Conclusion The clinical pathway plays not only a important role in improving the medical quality and in medical safety ,but also there are helps for improving the quality of medical records and raising the management of medical record .