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目的通过加强病案翻拍的各项质量管理,提高数字化病案质量。方法利用某院在病案翻拍过程中陆续发现的问题进行统计分析,针对问题采取以病案管理人员为主导的全程质量控制模式,完善三级质检机制,加强病案原始材料质控,规范数字化翻拍流程,对翻拍人员进行有关知识培训等措施。比较干预前后翻拍病案的质量变化。结果干预前病案翻拍质量合格率为94.88%,干预后提高到99.31%,经卡方检验,差异有统计学意义(P<0.005)。结论加强病案翻拍的全程质量管理,有效提高了翻拍病案质量,降低了病案的返拍率,保证了纸质病案的安全和完整的储存,充分发挥了翻拍病案的使用价值。
Objective To improve the quality of digital medical records by strengthening the quality management of medical records remake. Methods Using a hospital in the case of the remake of the case gradually found in the statistical analysis of the problem to take the case management staff as the mainstay of the entire quality control mode, improve the three quality inspection mechanisms, strengthen the quality of medical records of raw materials, standardized digital remake process , The remake of personnel for knowledge training and other measures. Compare the quality of the remake of medical records before and after intervention. Results Before the intervention, the qualified rate of the filming was 94.88%, after the intervention, it increased to 99.31%. The chi square test showed that the difference was statistically significant (P <0.005). Conclusion Strengthening the quality management of medical records remake effectively improves the quality of the remake records, reduces the rate of return of medical records, ensures the safety and complete storage of paper medical records, and gives full play to the value of using the remake records.