病案科内部工作质量监控方法的实践研究
周婧雅;赵青;赵轶超;赵晓娟;刘海;刘爱民
【期刊名称】《中国病案》 【年(卷),期】2017(018)004
【摘要】Objectives To investigate the feasibility of quality monitoring methods of internal work in medical record department.Methods Based on the quality monitoring indicators for the main parts of internal work in medical record department,we analyzed monitor data either from local net information system or manual auditing results in practical work.Results The reestablishment rate of medical record number,timely delivery rate of outpatient medical records,overdue and unreturnable rate of outpatient medical records as well as the collecting rate of inpatient medical records in less than 48 hours can be used to find the problems and loopholes in the current work.Auditing can significantly improve the quality of documentation filing,and the overall defect rate of filing reduced from 13.2％ to 9.1％,P＜0.05,in which the rate of major defects reduced from 6.5％ to 3.3％,P＜0.05.However,the effect of quality control on coding quality enhancement was not obvious,P＞0.05.Conclusion It is practically confirmed that the means of quality monitoring by combination of medical record tracing system and the manual check for filing and coding,c an timely and objectively reflect the deficiency and limitations of current work and help to improve the
病案科内部工作质量监控方法的实践研究
