基于广西某大型三甲医院病案首页质量现状干预评价研究

发布时间：2017-12-27 20:09

本文关键词：基于广西某大型三甲医院病案首页质量现状干预评价研究　出处：《广西医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:本研究通过对广西某三甲医院病案首页质量进行评价,找出电子病历中病案首页存在的主要问题;分析造成电子病历中病案首页存在缺陷的影响因素;对现有的质量管理措施进行评价,并从多角度有针对性的提出改进措施,为医院电子病历中病案首页质量管理的发展与完善提供依据。方法:通过对广西某大型三甲医院部分出院病案首页的科学质量管理,对比去年同期病案首页质量情况,做出系统的评价。采用文献分析法设计问卷,采取随机抽样,对该医院200名住院医师进行问卷调查。使用epidata3.1对回收的问卷进行双人双机录入,利用spss17.0对所有数据进行统计分析,主要运用率的卡方检验、logistics多因素回归分析进行统计描述,使用根因分析法找出影响住院病案首页质量的影响因素,从而提出科学合理的对策建议。结果:某医院从2016年9月份开始采取了一系列医院持续质量管理实施住院病案首页的措施,提取2016年9月至2017年3月份的出院病案首页按相关标准进行质量控制,共抽检病历5794份,缺席陷病历为1975份,病历缺陷率为34.09%,合格病历90.89%。缺误项共计3475个,主要分布为:患者基本信息缺误占21.76%,诊疗信息错漏占8.49%,手术操作信息错漏占29.90%,医师签名缺误占39.85%。从医院持续质量管理实施前后住院病历质量总体情况来看,缺陷病案首页数量有了明显的减少,降幅为48.50%,此外,产科病区、脊柱骨外科病区、心血管病区此类改进前缺陷病历较多的科室也有了长足进步。此外,影响病案首页质量情况的因素主要有医院管理职能部门,质量管理方法,住院医师,软硬件环境等四个方面。分别表现为:医院管理职能部门监管力度存在不足;医院管理职能部门开展的关于住院病案首页的培训较少;医院管理职能部门奖惩措施不够全面;质量控制的形式还较为单一;管理方法较为落后;住院医师对住院病案首页的重要性认识不足;住院医师参加学习及培训的次数较少;住院病案首页质量管理的软硬件环境仍存在局限。结论:广西某大型三甲医院病案首页干预取得了一定的效果,但仍然有待于进一步加强。此外,病案首页质量管理重点应从终末质控转移到对运行病历的实时质控,病案缺陷重在预防,才可有效杜绝修改病案的行为发生。
[Abstract]:Objective: This study of Guangxi medical hospital homepage quality evaluation, find out the existing main problems of medical records electronic medical records in the home; analysis of influence factors of medical records electronic medical records in home defects; evaluation of the quality management of the existing measures, and from multiple perspectives put forward the improvement measures, to provide the basis for the development and improvement of medical records electronic medical record quality management in home. Methods: through the scientific quality management of the first page of a large tertiary hospital in Guangxi, and comparing the quality of the first page of the medical record in the same period last year, we made a systematic evaluation. The questionnaire was designed by the method of literature analysis and random sampling was adopted to investigate 200 residents in the hospital. Using epidata3.1 the questionnaire double machine using SPSS17.0 to input all the data for statistical analysis, mainly using the rate of the chi square test, logistics regression analysis of statistical description, using root cause analysis to find out the influence factors affecting the quality of the medical record in hospital, so as to make scientific and reasonable suggestions. Results: the hospital began to take a series of hospital medical records of the continued implementation of the quality management measures from 2016 September 2016 to 2017 September, from March hospitalization medical records according to the relevant standards for quality control, sampling a total of 5794 medical records, medical records in the absence of 1975 copies, medical record defect rate was 34.09%, the qualified medical records 90.89%. The total number of missing items is 3475, which are mainly distributed as follows: 21.76% of the patients' basic information is missing, accounting for 8.49% of the diagnosis and treatment information, and 29.90% of the operative information and 39.85% of the physician's signature. From the hospital before and after the implementation of continuous quality management in the overall situation of the quality of medical records, medical record number of defects was reduced significantly, a decline of 48.50%, in addition, Department of Obstetrics, Department of surgery, cardiovascular department of spinal bone defects in medical records before this improvement more departments have made great progress. In addition, the main factors affecting the quality of the home page are four aspects, such as hospital management department, quality management method, resident doctor, software and hardware environment. Are as follows: the hospital management departments of supervision are insufficient; carry out hospital management departments on medical records less training; hospital management departments are not comprehensive incentive measures; quality control form is still single; the management method is relatively backward; resident insufficient understanding of the importance of medical records; residents in learning and training less; hospital medical record quality management software and hardware environment was still limited. Conclusion: the intervention of the first page of a medical record in a large three a hospital in Guangxi has achieved some effect, but it still needs to be further strengthened. Besides, the quality management of the front page of medical records should be shifted from the final quality control to the real-time quality control of the running medical records, and the defects of the medical records should be prevented before being able to effectively prevent the modification of medical records.
【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.323

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