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四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、内涵质量三方面进行汇总分析。结果监控前组和监控组比较，及时性达标率由79.4%提升到85.2%（P＜0.001），完整性达标率由94.9%提升到98.2%（P＜0.001），内涵质量达标率由91.8%提升到93.6%（P=0.114）；监控后第二年（2013年）发现运行病历书写及时性、完整性、内涵质量不达标情况分别集中在危重患者病程记录不及时、入院录不完整、日常病程记录内涵质量不高等方面；运行病历书写质量受书写人员的性别、学历、职称、科室因素影响。结论医疗质量实时监控系统的应用是提高运行病历书写及时性、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；女性、高职称、高学历、非手术科室的医务人员运行病历书写的质量较高。
목적：연구의료질량실시감공계통시부가이제고운행병력적서사질량。방법대실시감공전후공사년적운행병역서사질량진행회고성분석，감공전공추사960빈운행병력，감공후검사24255빈운행병력，종운행병역서사적급시성、완정성、내함질량삼방면진행회총분석。결과감공전조화감공조비교，급시성체표솔유79.4%제승도85.2%（P＜0.001），완정성체표솔유94.9%제승도98.2%（P＜0.001），내함질량체표솔유91.8%제승도93.6%（P=0.114）；감공후제이년（2013년）발현운행병역서사급시성、완정성、내함질량불체표정황분별집중재위중환자병정기록불급시、입원록불완정、일상병정기록내함질량불고등방면；운행병역서사질량수서사인원적성별、학력、직칭、과실인소영향。결론의료질량실시감공계통적응용시제고운행병역서사급시성、완정성적유효방법，단대제고운행병역서사적내함질량효과불명현；녀성、고직칭、고학력、비수술과실적의무인원운행병역서사적질량교고。
Objective: To study whether real-time monitoring system of medical quality can improve the writing quality of medical record. Methods: We reflectively analyzed the writing quality of medical records in the total four years before and after the real-time monitoring, and inspected randomly 960 medical records from before the monitoring and 24 255 after it. Then, we summarized and analyzed these medical records in three aspects of timeliness, integrity and connotation. Results: Before monitoring, the respective up-to-standard rates of timeliness, completeness, connotation of medical record were 79.4%, 94.9% and 91.8%, respectively. After monitoring, the respective up-to-standard rates of these three indicators were 85.2%, 98.2% and 93.6%, respectively. The timeliness and integrity of medical record showed a significant difference (P < 0.001), but connotation of the medical record writing (P=0.114) had no noticeable change. After monitoring, with time passing, the up-to-standard rate of integrity increased as a whole, the rate of connotation increased mildly, and the rate of timeliness increased first and then decreased. in 2013 after the monitoring, substandard of medical record timeliness mainly concentrated in superior doctors’ records of their first round, surgical security verification records, and hospital admission records. in 2013 after the monitoring, substandard of medical record integrity mainly concentrated in hospital admission records, 24 hours admission and discharge records, and surgical records. Conclusion: 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 obvious influence on connotation of the medical record writing.