中国卫生产业
中國衛生產業
중국위생산업
CHINA HEALTH INDUSTRY
2015年
11期
139-141
,共3页
王丽华%宁琼%李巧玲%李文红%熊维麟
王麗華%寧瓊%李巧玲%李文紅%熊維麟
왕려화%저경%리교령%리문홍%웅유린
病案质量%病案缺陷%质控分析
病案質量%病案缺陷%質控分析
병안질량%병안결함%질공분석
The quality of medical record%Defects of medical record%Quality analysis
目的：通过对某职业病医院终末病案质控分析并提出整改措施，以提高病案质量。方法对2013年10月-2014年9月的终末病历质量控制1659份，对缺陷进行汇总分析。结果内科、职业病科、外科甲级病案率分别为96.36%、98.30%、88.82%，全院甲级病案率为96.68%；外科病案甲级率低于内科系统；1659份病案中缺陷总数为2317个，缺陷率为139.66%。结论加强“三基三严”培训，提高科主任执行力，加强监管，及时维护电子病历系统，进而提高病案质量。
目的：通過對某職業病醫院終末病案質控分析併提齣整改措施，以提高病案質量。方法對2013年10月-2014年9月的終末病歷質量控製1659份，對缺陷進行彙總分析。結果內科、職業病科、外科甲級病案率分彆為96.36%、98.30%、88.82%，全院甲級病案率為96.68%；外科病案甲級率低于內科繫統；1659份病案中缺陷總數為2317箇，缺陷率為139.66%。結論加彊“三基三嚴”培訓，提高科主任執行力，加彊鑑管，及時維護電子病歷繫統，進而提高病案質量。
목적：통과대모직업병의원종말병안질공분석병제출정개조시，이제고병안질량。방법대2013년10월-2014년9월적종말병력질량공제1659빈，대결함진행회총분석。결과내과、직업병과、외과갑급병안솔분별위96.36%、98.30%、88.82%，전원갑급병안솔위96.68%；외과병안갑급솔저우내과계통；1659빈병안중결함총수위2317개，결함솔위139.66%。결론가강“삼기삼엄”배훈，제고과주임집행력，가강감관，급시유호전자병력계통，진이제고병안질량。
Objective By analyzing the quality of terminal medical record in one occupational disease hospital and put forward improvement measures, In order to improve the quality of medical record. Methods To Control quality of 1659 terminal medical records from October 2013 to September 2014 , analyze defects. Results The Serie record rate respectively of internal medicine, occupational medicine and surgery class is 96.36%、98.30%、88.82%,The total rate of class is 96.68%. The rate of surgery medical record class is lower than medicine system. The number of defects in 1659 medical record is 2317, Defect rate is 139.66%.Con-clusions We shoud strengthen "sanki steady tightening” training , increase execution of director, strengthen the supervision , maintain electronic medical record system in a timely manner,so as to improve the quality of medical record.
