病历质量控制两级随机盲态模式的构建与应用

发布时间：2018-04-25 22:03

本文选题：病历 + 质量　；参考：《第二军医大学》2017年硕士论文

【摘要】：病历的作用和重要性随着时代的进步发展,日益凸显。良好的病历质量不仅能推动医院医疗、教学、科研的发展,更在医保付费、保险报销、法律凭证、DRGs推广等方面发挥重大作用。然而当前的病历质量并不能完全满足社会和医学发展对其提出的新要求。主流的病历质量控制方法也有一定局限性,缺乏相应的责任落实保障机制以确保质控效果。研究目的本课题以提高病历质量,促进内涵建设为导向,针对当前病历质量控制工作易受干扰,工作质量无法保障的难题,旨在通过两级随机盲态模式的设计,建立科学严谨的病历质控工作模式和责任落实保证机制,以优化病历检查,完善工作监管,构建公正、公平、公开的质控工作环境,提高质控工作效能,同时借助责任化、常态化的质控模式,促进各科室抓好源头,持续改进病历书写质量。另一方面,结合工作需要,设计开发病历质控操作平台及信息发布系统,以提升质控工作效率,统一操作标准,优化病历整改流程,规范数据生成,减少人为因素造成的评价偏倚。研究方法和内容本研究通过对文献回顾、头脑风暴、专家访谈等方法,掌握当前医疗机构病历质量现状及主流病历质控方法,分析发现其中的缺陷不足,结合某医疗机构自身实践经验,构建一套以责任落实保障机制为核心的两级随机盲态化的病历质控模式,通过重组工作团队,转变工作方法,调整任务分工,规范信息发布,优化病历整改以及结果双盲抽检,问题反馈申诉,内涵优化评价,考核绩效挂钩等方法,优化团队结构,强化责任落实,提高质控效能,构建一个公平、公正、公开的质控环境。同时,为提高病历质控效能,与软件公司合作开发医院住院病历质控操作平台及信息发布系统,以实现质控工作高效,信息反馈及时,参与互动频繁,资料生成规范,统计查询流畅。最后,选取江苏省某三甲医院为试点,对构建的理论模式和信息系统展开实地应用,检验理论效果,并根据运行情况,提出整改意见和完善方向,最终实现“抓好环节,强化终末,迅速反馈,及时整改,提高内涵”的目的。研究结果1.新质控模式实施后,与2016年1月份病历质量同比发现,2017年1月份终末病历总体甲级病案率由90.6%上升至95.6%(P0.05),甲级病案率低于90%的病区数由13个降至5个(P0.05),严重缺陷病历由4例降至0例,病历全部及时归档。2.对一般缺陷情况进行分析发现,病程记录和基本规则辅助检查方面问题是内外科系终末病历问题共同的高发区。病程记录问题及入院记录问题是内外科系环节病历问题的高发区。病程记录问题是环节和终末病历问题的共同高发区。3.对病历内涵质量进行分析发现,“缺陷类别”问题主要集中在“作为不当”和“不作为”,“作为不当”占绝大比例。“缺陷后果类别”问题主要集中在“一般侵犯经济利益”。4.从检查人员工作考核情况来看,经过医院的针对性培训,检查人员能胜任质控工作,圆满完成任务,但还有改进空间。结论1.两级随机盲态化的质控模式提高了病历甲级病案率,降低了乙级、丙级病案率及病历缺陷率,加快了病历返修归档速度。此外,对病历内涵质量的质控评价也步入正轨,促进了病历内涵质量提升,有效引导和规范了医护人员的诊疗操作。2.新模式弥补了原先质控队伍人手不足,工作压力大,人员专业结构、分工不合理,检查效率低下的局面,提升了队伍执行任务的科学性。3.形成了人人能负责、敢负责、必须负责的质控环境,减少了人情等因素的干扰,确保工作公正公平、保质保量完成。同时,构建了一个沟通迅捷,反馈及时,操作有序,整改规范的病历质控管理闭合路径,提高了工作效率。该质控模式的实施,为解决当前病历检查工作质量无法保证,质控专家不受重视,质控工作易受干扰等问题找到了一条有效的解决途径,并且将病历内涵质量也纳入质控范围,有效促进了病历质量和内涵水平的提升。同时,该模式对医疗机构的硬件、软件要求相对较低,值得尝试推广。推行该模式时要注意整体把握,重视环节质量,细化内涵评价,要善于利用信息化手段,同时做好教育培训,抓好病历书写源头,促进医院文化形成。
[Abstract]:The role and importance of the medical records are becoming more and more important with the progress of the times. The good medical record quality can not only promote the development of hospital medical treatment, teaching and scientific research, but also play an important role in medical insurance pay, insurance reimbursement, legal voucher and DRGs promotion. However, the current medical record quality can not fully meet the development of society and medicine. New requirements. The mainstream medical record quality control method also has some limitations, the lack of corresponding responsibility implementation guarantee mechanism to ensure quality control effect. The purpose of the research is to improve the quality of the medical records, promote the connotation construction, and aim at the difficult problems of the current medical record quality control work, which are easily disturbed and the work quality can not be guaranteed. After the design of the two level random blind mode, a scientific and rigorous medical record quality control work mode and responsibility implementation guarantee mechanism are established to optimize the medical record inspection, improve the work supervision, build a fair, fair and open quality control work environment, improve the quality control work efficiency, and use the responsibility assignment and the normalization quality control mode, and promote the various departments to grasp the source well. On the other hand, the quality control operation platform and information publishing system are designed and developed to improve the efficiency of the quality control, the unified operation standard, the optimization of the medical record rectification process, the standardization of the data generation and the reduction of the evaluation bias caused by human factors. Review, brainstorming, expert interview and other methods, grasp the current medical records quality status and the mainstream medical record quality control method, analyze the defects and find out the defects. Combining with the practical experience of a medical institution, a set of two level random blind medical record quality control model with the responsibility implementation guarantee mechanism is constructed, and the reorganization work is carried out. The team, changing the work method, adjusting the task division, standardizing the information release, optimizing the medical record rectification and the double blind test, the problem feedback appeals, the connotation optimization evaluation, the performance linking and so on, optimize the team structure, strengthen the responsibility implementation, improve the quality control efficiency, construct a fair, just and open quality control environment. At the same time, in order to improve the disease, to improve the disease. In order to realize the high efficiency of the quality control work, the information feedback is timely, the participation of the information is frequent, the data is generated and the statistical query is fluent. Finally, a three a medical hospital in Jiangsu province is selected as the pilot, and the theoretical model and information system of the construction are carried out. Field application, test the theoretical effect, and according to the operation situation, put forward rectification opinions and improvement direction, finally realize the goal of "grasp the link, strengthen the end, feedback quickly, improve the connotation in time, improve the connotation". After the implementation of the 1. new quality control model of the research results, it was found on the same period of the medical records in January of 2016, and the final medical records of January 2017 were overall first grade. The rate of medical records increased from 90.6% to 95.6% (P0.05). The number of medical records below 90% was reduced from 13 to 5 (P0.05), and 4 cases were reduced from 4 cases to 0 cases, and all the cases were analyzed by.2.. The problem of record of the disease and the record of admission are the high incidence areas of the internal and external records of the Department of internal and external sciences. The problem of the record of the disease is the analysis of the quality of the medical record in the common high incidence area of the link and the end case history. The problem of "defect category" is mainly concentrated on "misconduct" and "Inaction", "as a misfit". The problem of "defect consequences category" is mainly focused on the "general violation of economic interests".4. from the inspection of the inspectors. Through the targeted training of the hospital, the inspectors can be qualified for quality control work and complete the task satisfactorily, but there is room for improvement. Conclusion the quality control model of 1. level two level random blindness improves the medical record. The grade a medical record rate has reduced the grade B, the rate of class C case and the rate of medical record defect, quickened the speed of medical record repair and filing. In addition, the quality control evaluation of medical records also stepped into the right track, promoted the quality of the medical record and improved the quality of medical records, and effectively guided and standardized the new.2. model of medical and nursing staff to make up for the shortage of the original quality control team. As a result of high pressure, professional structure, unreasonable division of labor and low efficiency, the scientific.3. of the team is responsible, responsible and responsible for the quality control environment, reducing the interference of factors such as human feelings, ensuring fair and fair work and completing the quality and quantity. At the same time, a communication and rapid communication is built. The implementation of the quality control model can not guarantee the quality of the current medical record inspection, the quality control experts are not paid attention to, and the quality control work is easily disturbed by the quality control, and the quality of the medical record is also included in the quality control. The scope of quality control has effectively promoted the improvement of medical record quality and connotation level. At the same time, the model is relatively low in hardware and software requirements for medical institutions, and it is worth trying to popularize. When the model is implemented, we should pay attention to the overall grasp, attach importance to the quality of the link, refine the connotation evaluation, make good use of information means, do a good job in education and training, and grasp the medical record. To write the source to promote the formation of the hospital culture.

【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.323

【参考文献】