环节病历时限性专项质控标准的制订与应用.docVIP

环节病历时限性专项质控标准的制订与应用 邵申申 张萍 中国人民解放军第九四医院 X 关注成功！ 加关注后您将方便地在 我的关注中得到本文献的被引频次变化的通知！ 新浪微博 腾讯微博 人人网 开心网 豆瓣网 网易微博 摘????要： 目的 制订环节病历时限性专项质控标准, 应用于环节病历时限性专项检查中。方法 根据《病历书写基本规范》, 应用德尔菲专家咨询法制订环节病历时限性专项质控标准, 并根据此项标准, 依托信息化平台, 应用电子病历质控系统对全院环节病历进行时限性专项检查。结果 最终制订的环节病历时限性专项质控标准包涵4个一级指标和25个二级指标;依据该标准对2017年5月某院1000份环节病历进行时限性专项检查, 按时完成的病历数为744份, 总体合格率为74.4%, 其中, 入院记录、手术记录及出院记录的合格率均达到95%以上, 而病程记录存在较大的时限性缺陷。结论 制订的环节病历时限性专项质控标准具有较高的科学性和可靠性, 可为环节病历质量控制提供科学依据, 同时对于提高医院整体病案质量具有重要意义。 关键词： 环节病历; 时限性; 专项质控; 收稿日期：2017-07-11 基金：江西省卫生计生委科技计划 Establishment and Application of Special Quality Control Standard for Time Effectiveness of Link Medical Records Shao Shenshen Zhang Ping No.94 Hospital of Chienes PLA; Abstract： Objectives To formulate the special quality control standard of the medical record timeliness, and apply it to the special examination of the timeliness of the medical record. Methods According to the basic norms of medical records, Delphy used expert consultation method to develop special timeliness link medical records quality control standards, and according to this standard, based on the information platform, the application of electronic medical record quality control system for the timeliness of the special inspection of the link of medical records.Results The final formulation of the timeliness of the special link medical records quality control standard includes 4 first grade indexes and 25 level two indexes; on the basis of the timeliness of the special inspection of the hospital in May 2017 1000 link medical records were the standard, the number of records completed on time is 744, the overall pass rate was 74.4%, among them, hospital records, surgical records and discharge records of qualified rate reached more than 95%, while the course record exists timeliness defect. Conclusions The special quality control standard of medical record timeliness had high scientific and reliability. It could provide scientific basis for the quality control of me