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目的加强病案提交环节质量监控,确保病案质量。方法从2008年1月始对每份提交的病案进行质量监控,并对2007年和2008年提交的病案进行质量对比分析。结果2007年提交病案38853份,缺陷病案1656份,缺陷率4.26%。2008年提交病案41979份,缺陷病案262份,缺陷率0.62%。经卡方检验,P<0.01,统计学有明显差异。2008年提交病案的各项目缺陷情况较2007年明显地减少。结论加强病案环节质量监控,能有效保证病案质量。
Objective To strengthen the quality control of medical record submission and ensure the medical record quality. Methods From January 2008, the quality of every submitted medical record was monitored and the quality of the medical records submitted in 2007 and 2008 was analyzed. Results 38853 medical records were submitted in 2007, 1656 were defective and 4.26% were defective. 41,979 medical records were submitted in 2008, with 262 medical defects and a defect rate of 0.62%. The chi-square test, P <0.01, statistically significant differences. The deficiencies in various projects submitted to medical records in 2008 were significantly reduced from those in 2007. Conclusion Strengthening the quality control of medical records can effectively ensure the quality of medical records.