住院医师参与病案检查对病案质量的影响.pdfVIP

《中国病案》2016 年第 17 卷第 10 期 ·21· 住院医师参与病案检查对病案质量的影响 ① ①* 邹 庞 罗建章 摘要 目的 探讨住院医师参与病案检查对其书写的病案质量的影响。方法 按是否参与病案检查将研 究对象分为实验组和对照组。比较实验组参与病案检查前后的病案优秀率，分别比较实验组和对照组 2014 年度和 2015 年度的病案优秀率，利用 EXCEL 整理数据，并应用统计软件 SPSS19.0 对病案优秀率进行卡 方检验。结果 实验组 2015 年度的病案优秀率明显高于 2014 年度（P ＜0.001）；2015 年度，实验组的病案 优秀率明显高于对照组（P ＜0.001）。结论 住院医师参与病案检查可显著改进其书写的病案质量。 关键词 住院医师；改进；病案质量 ① Impact of Residents to Participate in the Medical Record Check on the Quality of Medical Records Zou Pang , ①* Luo Jianzhang , The First Hospital of Longyan, Longyan 364000, Fujian Province, China Abstract Objective To investigate the impact of residents to participate in the medical record check on the quality of medical records that written by them. Methods The research objects were divided into the experimental group and control group according to whether or not to participate in medical record check. Compared the excellent rate of medical records before and after participating in medical record check. Compared the excellent rate of medical records that written by the experimental group and control group in 2014 and in 2015. Analyzing the excellent rate of medical records by Excel and Spss19.0. Results The excellent rate of medical records that written by experimental group in 2015 is obviously better than in 2014 ( P ＜0.001). The excellent rate of medical records in 2015 that written by experimental group is obviously better than control group ( P ＜0.001). Conclusion Residents to participate in the medical record check can significantly improve the quality of medical records that written by them. Key words Residents; Improve; Quality