病案中高值耗材条形码粘贴质量管理.pdfVIP

·4· 《中国病案》2015 年第 16 卷第 5 期 ·病案管理· 病案中高值耗材条形码粘贴质量管理 100020 北京市 首都医科大学附属北京朝阳医院 张玉华 徐向天* 摘要 目的 通过分析病案中高值耗材条形码粘贴中的问题并提出改进措施，以提高条形码粘贴的质 量。方法 调阅心脏中心导管室整改前整改后 1 个月以及整改后 1 年使用高值耗材的出院病案，对条形码 粘贴情况进行统计分析。结果 整改前条形码粘贴率为 37%，条形码粘贴于经皮冠状动脉介入治疗（PCI） 报告上 12 份（14%）、冠状动脉造影报告上 43 份（50%）、永久起搏器和 ICD 手术记录上 7 份（8%）、介 入诊断与治疗记录上 24 份（28%）。整改后 1 个月和 1 年高值耗材条形码粘贴率分别为 86%和 95%，使用专 用高值耗材条形码粘贴单的比例分别为 5%和 100%。结论 通过分析病案中高值耗材条形码粘贴问题,采取制 定管理制度和粘贴单、培训、加大检查力度等改进措施可有效提高高值耗材条形码的粘贴率及粘贴质量。 关键词 病案；高值耗材；条形码；管理；可追溯性 Quality Management of Stripe Code Pasting of High-profit Consumables in Medical Records Zhang Yuhua, Xu Xiangtian*, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing 100020, China Abstract Objective To analyze the problems existing in the pasting process of stripe code pasting of high-profit consumables in medical records and put forward improvement measures, so as to improve the pasting quality of stripe code. Methods To investigate the discharged medical records that had used high profit consumables 1 month before and after the rectification of cardiac catheterization center, and conduct analysis on the pasting situation of stripe-code. Results Before rectification, the pasting rate of high profit consumable stripe-coding was 37%, 12 (14%) located on the report of percutaneous coronary intervention, 43 (50%) pasted on the report of coronary angiograms, 7 (8%) pasted on the records of permanent pacemaker implantation or ICD operation records and 24 (28%) pasted on records of interventional diagnosis and treatment. The pasting rate of stripe code of high-profit consumables were respectively 86% and 95% one month and one year after the rectification, and the proportion of specific stripe-coding paste sheet were 5% and 100% respectively. Conclusions Through the analysis on the pasting problems of