本文關(guān)鍵詞：基于廣西某大型三甲醫(yī)院病案首頁(yè)質(zhì)量現(xiàn)狀干預(yù)評(píng)價(jià)研究　出處：《廣西醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 三甲醫(yī)院 病案首頁(yè) 質(zhì)量管理 評(píng)價(jià)

【摘要】：目的:本研究通過(guò)對(duì)廣西某三甲醫(yī)院病案首頁(yè)質(zhì)量進(jìn)行評(píng)價(jià),找出電子病歷中病案首頁(yè)存在的主要問(wèn)題;分析造成電子病歷中病案首頁(yè)存在缺陷的影響因素;對(duì)現(xiàn)有的質(zhì)量管理措施進(jìn)行評(píng)價(jià),并從多角度有針對(duì)性的提出改進(jìn)措施,為醫(yī)院電子病歷中病案首頁(yè)質(zhì)量管理的發(fā)展與完善提供依據(jù)。方法:通過(guò)對(duì)廣西某大型三甲醫(yī)院部分出院病案首頁(yè)的科學(xué)質(zhì)量管理,對(duì)比去年同期病案首頁(yè)質(zhì)量情況,做出系統(tǒng)的評(píng)價(jià)。采用文獻(xiàn)分析法設(shè)計(jì)問(wèn)卷,采取隨機(jī)抽樣,對(duì)該醫(yī)院200名住院醫(yī)師進(jìn)行問(wèn)卷調(diào)查。使用epidata3.1對(duì)回收的問(wèn)卷進(jìn)行雙人雙機(jī)錄入,利用spss17.0對(duì)所有數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析,主要運(yùn)用率的卡方檢驗(yàn)、logistics多因素回歸分析進(jìn)行統(tǒng)計(jì)描述,使用根因分析法找出影響住院病案首頁(yè)質(zhì)量的影響因素,從而提出科學(xué)合理的對(duì)策建議。結(jié)果:某醫(yī)院從2016年9月份開(kāi)始采取了一系列醫(yī)院持續(xù)質(zhì)量管理實(shí)施住院病案首頁(yè)的措施,提取2016年9月至2017年3月份的出院病案首頁(yè)按相關(guān)標(biāo)準(zhǔn)進(jìn)行質(zhì)量控制,共抽檢病歷5794份,缺席陷病歷為1975份,病歷缺陷率為34.09%,合格病歷90.89%。缺誤項(xiàng)共計(jì)3475個(gè),主要分布為:患者基本信息缺誤占21.76%,診療信息錯(cuò)漏占8.49%,手術(shù)操作信息錯(cuò)漏占29.90%,醫(yī)師簽名缺誤占39.85%。從醫(yī)院持續(xù)質(zhì)量管理實(shí)施前后住院病歷質(zhì)量總體情況來(lái)看,缺陷病案首頁(yè)數(shù)量有了明顯的減少,降幅為48.50%,此外,產(chǎn)科病區(qū)、脊柱骨外科病區(qū)、心血管病區(qū)此類改進(jìn)前缺陷病歷較多的科室也有了長(zhǎng)足進(jìn)步。此外,影響病案首頁(yè)質(zhì)量情況的因素主要有醫(yī)院管理職能部門,質(zhì)量管理方法,住院醫(yī)師,軟硬件環(huán)境等四個(gè)方面。分別表現(xiàn)為:醫(yī)院管理職能部門監(jiān)管力度存在不足;醫(yī)院管理職能部門開(kāi)展的關(guān)于住院病案首頁(yè)的培訓(xùn)較少;醫(yī)院管理職能部門獎(jiǎng)懲措施不夠全面;質(zhì)量控制的形式還較為單一;管理方法較為落后;住院醫(yī)師對(duì)住院病案首頁(yè)的重要性認(rèn)識(shí)不足;住院醫(yī)師參加學(xué)習(xí)及培訓(xùn)的次數(shù)較少;住院病案首頁(yè)質(zhì)量管理的軟硬件環(huán)境仍存在局限。結(jié)論:廣西某大型三甲醫(yī)院病案首頁(yè)干預(yù)取得了一定的效果,但仍然有待于進(jìn)一步加強(qiáng)。此外,病案首頁(yè)質(zhì)量管理重點(diǎn)應(yīng)從終末質(zhì)控轉(zhuǎn)移到對(duì)運(yùn)行病歷的實(shí)時(shí)質(zhì)控,病案缺陷重在預(yù)防,才可有效杜絕修改病案的行為發(fā)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.
【學(xué)位授予單位】：廣西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R197.323

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