CAJ | 학술논문

目的：将病案评估结果作为对医生资格、晋升、晋职及能力评价的依据，探讨病案质量持续改进的方法与措施。方法选取2013年1月-6月和7月-11月，即新评价制度推行前后某院所有病案共96651份，分析内科、外科、专科和全院病案质量是否有改善及不同单项否决项目所占构成比有无改变。结果新评价制度实施后内科、外科、专科和全院的缺陷病案率和单否病案率均显著降低（P＜0.01），对单项否决项目所占构成比的影响无统计学意义（P=0.884）。结论新评价制度推行后，通过实施加强病历书写培训；严格落实三级医师责任制；加强环节质量管理；重视终末病案质量分析；完善奖惩制度等方法，使得病案质量显著提高，值得推广。
목적：장병안평고결과작위대의생자격、진승、진직급능력평개적의거，탐토병안질량지속개진적방법여조시。방법선취2013년1월-6월화7월-11월，즉신평개제도추행전후모원소유병안공96651빈，분석내과、외과、전과화전원병안질량시부유개선급불동단항부결항목소점구성비유무개변。결과신평개제도실시후내과、외과、전과화전원적결함병안솔화단부병안솔균현저강저（P＜0.01），대단항부결항목소점구성비적영향무통계학의의（P=0.884）。결론신평개제도추행후，통과실시가강병역서사배훈；엄격락실삼급의사책임제；가강배절질량관리；중시종말병안질량분석；완선장징제도등방법，사득병안질량현저제고，치득추엄。
Objective To analyze the influence of new evaluation standard on the medical record quality, and discuss the methods to improve medical record quality continuously.Methods We choose 96651 medical records before(from January to June,2013) and after(from July to November,2013) the implementation of the new evaluation standard, and analyze the improvement of medical record quality in the departments of internal medicine, surgery, specialties and the whole hospital, as well as the changes in the constituent ratio of single item denial. Results After the implementation of the new evaluation standard, the defect rate and single item denial rate of medical records significantly decreased(P<0.01), yet it did not change the constituent ratio of single item denial (P=0.884).Conclusion The management of medical record quality is a long-lasting job, we should pay high attention to Strengthen the education of the medical record writing, Strictly implement the responsibility system for Three-levels physician, Strengthen the link quality management, attaches great importance to the terminal medical record quality analysis,Improve the system of rewards and punishments to Make the medical record quality significantly improved.