医保病历书写质量缺陷与管理
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摘要
目的分析医保病历书写质量缺陷及实施品管圈管理对病历书写质量的影响。方法选择某三甲医院2015年1月-2016年1月医保病历3 045份(品管圈实施前)和2016年12月-2017年12月医保病历3 080份(品管圈实施后),采用医院自制病历书写缺陷调查表分析病历缺陷情况,比较品管圈管理前后病历书写质量。结果实施品管圈管理后病历甲级率为81.89%高于管理前的72.38%,实施品管圈管理后病历缺陷率为14.56%低于管理前的20.69%,差异均有统计学意义(P<0.05)。品管圈管理前后医保病历书写缺陷的主要问题均为未按规定时间记录病程、三级查房内容雷同、主任医师首次查房无分析、次要诊断缺乏依据、用药指征记录不全等。结论在医保病历书写过程中采用品管圈管理可明显改善病历书写的完整性,提高病历书写质量。
Objective To analyze the quality defects of medical record writing and the effect of the campaign of quality control circle on the quality of medical record writing.Methods 3 045 medical insurance records from January 2015 to January 2016 and 3 080 medical insurance cases from December 2016 to December 2017 in a tertiary Hospital were selected,and the occurrence of medical record defects was analyzed by using self-made medical record writing defect questionnaires,the quality of medical records before and after management of quality control circles was compared.Results After the implementation of the quality control circle management,the rate of Grade A(81.89%) was higher than before the implementation(72.38%),the defect rate(14.56%)was lower than before the implementation(20.69%),the differences were statistically significant(P<0.05).The failure to record the course of the disease according to the prescribed time,the similarity of the three-level ward round,the first analysis of the first doctor′s room,the lack of basis for secondary diagnosis,and the incomplete records of medication indications were the main problems of medical insurance medical records before and after management.Conclusion In the course of medical record writing,the integrity of medical record writing can be significantly improved by using the management mode of quality control circle,so the quality of medical records has been greatly improved.
Objective To analyze the quality defects of medical record writing and the effect of the campaign of quality control circle on the quality of medical record writing.Methods 3 045 medical insurance records from January 2015 to January 2016 and 3 080 medical insurance cases from December 2016 to December 2017 in a tertiary Hospital were selected,and the occurrence of medical record defects was analyzed by using self-made medical record writing defect questionnaires,the quality of medical records before and after management of quality control circles was compared.Results After the implementation of the quality control circle management,the rate of Grade A(81.89%) was higher than before the implementation(72.38%),the defect rate(14.56%)was lower than before the implementation(20.69%),the differences were statistically significant(P<0.05).The failure to record the course of the disease according to the prescribed time,the similarity of the three-level ward round,the first analysis of the first doctor′s room,the lack of basis for secondary diagnosis,and the incomplete records of medication indications were the main problems of medical insurance medical records before and after management.Conclusion In the course of medical record writing,the integrity of medical record writing can be significantly improved by using the management mode of quality control circle,so the quality of medical records has been greatly improved.
引文
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[2] 倪世杰,胡孝霆.从医保扣费环节规范病历书写质量[J].世界最新医学信息文摘,2015,15(40):173-174.DOI:10.3969/j.issn.1671-3141.2015.40.144.
[3] 钟旋,卢建军,刘秋生.二胎政策下产科病历书写质量分析及管理对策[J].中国卫生质量管理,2017,24(6):319-320.DOI:10.13912/j.cnki.chqm.2017.24.6.12.
[4] 谢敏,唐建中.对提高我院外科病历书写质量的探讨[J].中国医疗管理科学,2017,7(2):37-40.DOI:10.3969/j.issn.2095-7432.2017.02.009.
[5] 潘胜东,夏萍,徐莉,等.规范日间手术病历书写若干问题的思考[J].中华医院管理杂志,2017,33(10):781-783.DOI:10.3760/cma.j.issn.1000-6672.2017.10.019.
[6] 丁雄,吴风富,宋莹.品管圈与戴明环在医保病案质量管理中的应用[J].现代医院管理,2015,10(4):72-74.DOI:10.3969/j.issn.1672-4232.2015.04.024.
[7] 俞德梁,宁鹏涛,王娟,等.关于日间手术定义与首批推荐适宜手术的思考[J].医学与哲学,2015,36(24):5-7,14.
[8] 王淼,陈萍,吴佳璇,等.508份运行病历质量缺陷原因分析及改进措施探讨[J].卫生职业教育,2014,32(15):115-117.
[9] 李君兰,李瑞琴,柴文宁,等.2554份输血病历规范性调查[J].甘肃医药,2018,37(2):141-142.DOI:10.15975/j.cnki.gsyy.2018.02.019.
[10] 黄映嫦,姚慧梅,喻瑛.根本原因分析法在护理电子病历书写质量控制中的应用[J].承德医学院学报,2018,35(1):89-90.DOI:10.15921/j.cnki.cyxb.2018.01.040.