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目的通过对比实施多环节质控前后终末病案的质控结果,探究提高终末病案质量的有效途径。方法分别抽取2012年度、2013年度环节质控前后终末病案进行缺陷分析,并利用SPSS11.0统计软件进行统计学比较。结果多环节质控病案后,终末病案总缺陷率由25%下降至12%,各缺陷项目所占比例明显下降,且手术科室病案缺陷率下降,均有统计学差异,医疗纠纷亦有所减少。结论严格落实实施多环节质控病案较传统单一模式的终末病案质控有着显著优势,使终末病案缺陷率明显下降,尤其是手术科室的病案缺陷率明显下降,使得病历书写质量显著提高,某种程度上降低了医疗纠纷事件的发生,故加强多环节病案质控对提高病案质量有重要意义。
Objective To compare and analyze the quality control results of the final medical records before and after the multi-session quality control and explore the effective ways to improve the quality of the final medical records. Methods The defects of the final medical records before and after the quality control in 2012 and 2013 were analyzed and compared by SPSS11.0 statistical software. Results After the multi-link quality control medical record, the total defect rate of the final medical record dropped from 25% to 12%, the proportion of each defect item decreased obviously, and the rate of the medical record defect decreased, both of which were statistically different cut back. Conclusion Strict implementation of multi-link quality control case compared with the traditional single mode of end-result quality control has a significant advantage, so that the rate of end-item defects significantly reduced, especially in surgical departments of the case rate significantly reduced, making the writing quality significantly improved, To a certain extent, reduce the incidence of medical disputes. Therefore, it is of great significance to strengthen the quality control of medical records in multiple links.