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目的评估改进骨科病历归档流程对提高科室医疗质量管理水平的效果。方法针对2008年5月-2009年4月出院病历归档流程环节多、重复性审核等问题进行分析,于2009年6月-2010年5月采用减少环节,三方监督等办法改善其流程,并就改进前后的病历归档时间及归档率进行比较。结果改进后出院病历平均归档时间从5.8 d缩短到3.2 d,按期归档率从70.3%上升到99.8%,差异均具有统计学意义(P<0.05)。结论病历归档流程的改进有效提高了病历归档率,减少医护人员工作量,提高科室医疗质量管理,值得推广。
Objective To evaluate the effect of improving the archiving process of orthopedics records to improve the quality of departmental medical management. Methods From May 2008 to April 2009, there were many aspects of the archiving process of discharge records and repetitive audits. From June 2009 to May 2010, the procedures of reduction, tripartite supervision and other measures were adopted to improve the procedure Before and after the improvement of medical records archiving time and filing rate for comparison. Results After the improvement, the average archiving time of discharged patients was shortened from 5.8 days to 3.2 days, and the archival filing rate increased from 70.3% to 99.8%. The differences were statistically significant (P <0.05). Conclusion The improvement of medical record filing process has effectively improved the filing rate of medical records, reduced the workload of medical staff, and improved the medical quality management of department, which is worthy of promotion.