面向临床路径的病案质量监控体系研究
发布时间：2019-02-12 23:34
【摘要】：目的 在文献分析和实证调查的基础上，吸取病案质量监控的既有研究经验，并根据问卷调查、知情人访谈、德尔菲法等方法提出临床路径的病案质量监控内容，制定科学的监控方法、监控流程以及监控组织和制度，共同形成一套完善的面向临床路径的病案质量监控体系，达到规范临床路径的医疗行为、提高临床路径的病案质量，使临床路径的制定和执行者能够更好地利用病案信息于临床路径，进而促使我国临床路径的病案书写达到规范化的目的。 方法 采用定量研究与定性研究相结合的方法进行分析。主要方法包括：（1）文献复习法：利用中外知名数据库以及搜索引擎，，检索和查询国内外有临床路径与病案质量监控的理论、方法及研究成果；（2）现场调查：通过问卷调查、知情人访谈等方法对医师的病案书写、医院的病案质量监控方法、流程、应用效果和存在问题、进行调查与分析；（3）数理统计法：运用描述性统计方法分析病历书写情况和病案的质量监控现状；（4）专家咨询法：运用专家咨询法提炼出出临床路径的病案质量监控内容。 结果 （1）利用问卷调查、知情人访谈和文献研究了解到：目前的尚未有医院开展面向临床路径的病案质量监控，医师和管理人员对临床路径的了解较少，对病历书写规范和ICD编码的熟悉程度也不够；现医院多采用四级病案质量监控，但存在不重视环节质控，病历各部分书写的时限不能被监控，病历出科前没有重点进行内涵质量控制，监控力度不够，奖惩执行不严，监控效果不明显等问题。 （2）运用德尔菲法，以急性心肌梗死为例，经过两轮专家咨询确定了在病案首页、出院（死亡）记录、入院记录（或再次入院记录）、病程记录、医嘱单及辅助检查单五个维度下的16条面向临床路径的病案质量监控具体内容，并加入到病历质量考核评分标准中。 （3）确定了医院病案质量委员会的组织人员及其工作职责，提出了面向临床路径的病案质量监控方法和流程，重点在于责任落实到每一层人员以及每个环节的质控要点，制定了病案质量检查的奖惩制度和评分标准。构建了一套完整的面向临床路径的病案质量监控体系。 结论 （1）目前医院的病案质量监控效果不佳，医师和病案人员对临床路径与病历书写的重视程度和相关规范的了解程度不够，对面向临床路径的病案质量监控规范的研究十分必要。 （2）提出了对提高临床路径的病案质量的几条建议：加强对临床医师的培训；提高病案管理人员的专业素质；制定临床路径的病案质量监控标准。
[Abstract]:Objective on the basis of literature analysis and empirical investigation, to draw on the existing research experience of medical record quality monitoring, and to put forward the contents of medical record quality monitoring based on questionnaire, insiders interview, Delphi method and so on. To establish a scientific monitoring method, monitoring process, monitoring organization and system, to form a set of perfect medical record quality monitoring system for clinical pathway, to standardize the medical behavior of clinical pathway, and to improve the quality of clinical path. The establishment and implementation of the clinical pathway can make better use of the medical record information in the clinical pathway, and promote the writing of the medical record of the clinical pathway in our country to achieve the purpose of standardization. Methods quantitative analysis and qualitative analysis were used. The main methods are as follows: (1) Literature review: using well-known databases and search engines at home and abroad to retrieve and query the theories, methods and research results of quality monitoring of clinical pathway and medical records at home and abroad; (2) On-site investigation: investigation and analysis of physician's medical record writing, hospital's medical record quality monitoring method, process, application effect and existing problems by means of questionnaire investigation, insiders interview and so on; (3) Mathematical statistics: the descriptive statistical method is used to analyze the status quo of medical record writing and the quality control of medical record; (4) expert consultation method is used to extract the content of medical record quality control of clinical pathway. Results (1) by using questionnaires, insiders interviews and literature studies, it was found that no hospital has carried out medical record quality monitoring for clinical pathway at present, and doctors and administrators have little understanding of clinical pathway. Not enough familiarity with the standard of medical record writing and ICD code; At present, most hospitals adopt the quality control of medical records at four levels, but they do not attach importance to the quality control of links, the time limit for the writing of each part of the medical records cannot be monitored, the medical records do not focus on the connotation quality control before the medical records leave the department, the monitoring efforts are not enough, the rewards and punishments are not strictly executed. The monitoring effect is not obvious and so on. (2) using Delphi method, taking acute myocardial infarction as an example, two rounds of expert consultation were used to determine the records of discharge (death), hospital admission (or re-admission), course of disease, and the first page of the medical record. Under the five dimensions of the doctor's order list and the auxiliary examination sheet, 16 medical record quality monitoring contents oriented to the clinical path were included in the quality assessment and scoring standard of the medical record. (3) the organization and responsibility of the hospital medical record quality committee are determined, and the method and process of medical record quality monitoring oriented to clinical path are put forward. The key points of quality control for each layer of personnel and each link are put forward, and the emphasis is on the implementation of the responsibility to each level of personnel and the key points of quality control in each link. The system of rewards and punishments for medical record quality examination and the scoring standard were established. A complete medical record quality monitoring system for clinical pathway was constructed. Conclusion (1) at present, the quality control of medical records in hospitals is not good, and doctors and medical records personnel pay less attention to clinical path and medical record writing and know less about relevant norms. It is necessary to study the quality monitoring standard of medical record oriented to clinical pathway. (2) several suggestions are put forward to improve the quality of the medical record of the clinical pathway: strengthening the training of the clinicians, improving the professional quality of the medical record management personnel, and formulating the quality control standard of the medical record of the clinical pathway.
【学位授予单位】：华中科技大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R197.323
本文编号：2420909
[Abstract]:Objective on the basis of literature analysis and empirical investigation, to draw on the existing research experience of medical record quality monitoring, and to put forward the contents of medical record quality monitoring based on questionnaire, insiders interview, Delphi method and so on. To establish a scientific monitoring method, monitoring process, monitoring organization and system, to form a set of perfect medical record quality monitoring system for clinical pathway, to standardize the medical behavior of clinical pathway, and to improve the quality of clinical path. The establishment and implementation of the clinical pathway can make better use of the medical record information in the clinical pathway, and promote the writing of the medical record of the clinical pathway in our country to achieve the purpose of standardization. Methods quantitative analysis and qualitative analysis were used. The main methods are as follows: (1) Literature review: using well-known databases and search engines at home and abroad to retrieve and query the theories, methods and research results of quality monitoring of clinical pathway and medical records at home and abroad; (2) On-site investigation: investigation and analysis of physician's medical record writing, hospital's medical record quality monitoring method, process, application effect and existing problems by means of questionnaire investigation, insiders interview and so on; (3) Mathematical statistics: the descriptive statistical method is used to analyze the status quo of medical record writing and the quality control of medical record; (4) expert consultation method is used to extract the content of medical record quality control of clinical pathway. Results (1) by using questionnaires, insiders interviews and literature studies, it was found that no hospital has carried out medical record quality monitoring for clinical pathway at present, and doctors and administrators have little understanding of clinical pathway. Not enough familiarity with the standard of medical record writing and ICD code; At present, most hospitals adopt the quality control of medical records at four levels, but they do not attach importance to the quality control of links, the time limit for the writing of each part of the medical records cannot be monitored, the medical records do not focus on the connotation quality control before the medical records leave the department, the monitoring efforts are not enough, the rewards and punishments are not strictly executed. The monitoring effect is not obvious and so on. (2) using Delphi method, taking acute myocardial infarction as an example, two rounds of expert consultation were used to determine the records of discharge (death), hospital admission (or re-admission), course of disease, and the first page of the medical record. Under the five dimensions of the doctor's order list and the auxiliary examination sheet, 16 medical record quality monitoring contents oriented to the clinical path were included in the quality assessment and scoring standard of the medical record. (3) the organization and responsibility of the hospital medical record quality committee are determined, and the method and process of medical record quality monitoring oriented to clinical path are put forward. The key points of quality control for each layer of personnel and each link are put forward, and the emphasis is on the implementation of the responsibility to each level of personnel and the key points of quality control in each link. The system of rewards and punishments for medical record quality examination and the scoring standard were established. A complete medical record quality monitoring system for clinical pathway was constructed. Conclusion (1) at present, the quality control of medical records in hospitals is not good, and doctors and medical records personnel pay less attention to clinical path and medical record writing and know less about relevant norms. It is necessary to study the quality monitoring standard of medical record oriented to clinical pathway. (2) several suggestions are put forward to improve the quality of the medical record of the clinical pathway: strengthening the training of the clinicians, improving the professional quality of the medical record management personnel, and formulating the quality control standard of the medical record of the clinical pathway.
【学位授予单位】：华中科技大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R197.323
【引证文献】
相关期刊论文 前1条
1 杨凌燕;;病案信息化过程中质量监控及风险防范[J];现代仪器与医疗;2013年05期
本文编号：2420909
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