CAJ | 학술논문

目的:研究医疗质量实时监控系统是否可以提高运行病历的书写质量.方法:对实时监控前后共4年的运行病历书写质量进行回顾性分析,监控前共抽查960份运行病历,监控后检查24255份运行病历,从运行病历书写的及时性、完整性、内涵质量3个方面进行汇总分析.结果:监控前,运行病历书写的及时性、完整性、内涵质量的达标率分别为79.4%、94.9%、91.8%;监控后,3个指标的达标率分别为85.2%、98.2%、93.6%,病历书写及时性、完整性较监控前具有显著性差异(P<0.001),而病历书写内涵质量并无显著差异(P=0.114);监控后随时间变化,运行病历完整性达标率整体呈上升趋势,运行病历内涵质量达标率有轻度上升,运行病历及时性达标率先下降后上升.结论:医疗质量实时监控系统的应用是提高运行病历书写的及时性、完整性的有效方法,但对提高运行病历书写的内涵质量效果不明显.
목적:연구의료질량실시감공계통시부가이제고운행병력적서사질량.방법:대실시감공전후공4년적운행병역서사질량진행회고성분석,감공전공추사960빈운행병력,감공후검사24255빈운행병력,종운행병역서사적급시성、완정성、내함질량3개방면진행회총분석.결과:감공전,운행병역서사적급시성、완정성、내함질량적체표솔분별위79.4%、94.9%、91.8%;감공후,3개지표적체표솔분별위85.2%、98.2%、93.6%,병역서사급시성、완정성교감공전구유현저성차이(P<0.001),이병역서사내함질량병무현저차이(P=0.114);감공후수시간변화,운행병력완정성체표솔정체정상승추세,운행병력내함질량체표솔유경도상승,운행병력급시성체표솔선하강후상승.결론:의료질량실시감공계통적응용시제고운행병역서사적급시성、완정성적유효방법,단대제고운행병역서사적내함질량효과불명현.
Objectives: To study whether real-time monitoring system of medical quality can improve the writing quality of medical record. Methods: Retrospective analysis are made to compare the writing quality of medical records in four years before and after the real-time monitoring. 960 and 24255 medical records were randomly selected before and after implementing real time monitoring respectively. Timeliness, integrity and connotation of medical records were analyzed. Results: Before the monitoring,the respective up-to-standard rate of timeliness, completeness, connotation of medical record is 79.4%, 94.9% and 91.8%, and after monitoring,the respective up-to-standard rate of these three indicators is 85.2%, 98.2% and 93.6%. The timeliness and integrity of medical record shows a significant difference(P<0.001),but connotation of the medical record writing (P=0.114) has no significant change. After the monitoring, with time passing,the up-to-standard rate of integrity rises as a whole, the rate of connotation rises mildly, and the rate of timeliness rises first and then falls. Conclusions: Medical quality real-time monitoring and control system is an effective method to improve the timeliness and integrity of medical record writing but has no significant influence on connotation of the medical record writing.