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目的探讨病案管理前移模式在提高病案质量中的应用。方法随机抽取某三级甲等医院2015年(病案管理前移前)、2016年(病案管理前移后)1月-12月临床科室终末病案各2500份进行统计分析。结果实施病案管理前移后,病案7日归档率显著提高,内科由病案管理前移前的88.75%上升为99.75%,外科由病案管理前移前的85.29%上升为96.20%,差异有统计学意义;病案等级有明显改善,甲级病案由病案管理前移前68%提高至99%,乙级病案由30%降为0.87%,丙级病案由2%降为0.03%,外科甲级病案由病案管理前移前50.2%提高至64.2%,乙级病案由42.3%降为35.2%,丙级病案由7.5%降为0.6%,且有统计学差异。结论病案管理前移模式可以提高病案质量,减少医疗纠纷,提高病案7日归档率,可在医院内推广使用。
Objective To explore the application of medical records management forward mode in improving medical record quality. Methods A total of 2,500 cases of terminal disease in clinical departments from January to December in 2016 were collected randomly from a tertiary level hospitals in 2015 (before medical records management) and 2016 (after medical records management moved forward). Results After the medical records management was advanced, the filing rate of medical records increased significantly on the 7th day. The medical records increased from 88.75% before medical records management to 99.75%, while the surgical records increased from 85.29% to 96.20% before medical records management, the difference was statistically significant The grade of medical record has been significantly improved. Grade A medical record increased from 68% to 99% before case management, from 30% to 0.87%, from 2% to 0.03% From 50.2% before the case management advancement to 64.2%, from 42.3% to 35.2% and from 7.5% to 0.6%, and there was a statistically significant difference. Conclusion The mode of advancement of medical record management can improve the quality of medical record, reduce the medical dispute and improve the filing rate of medical record on the 7th day, which can be promoted in the hospital.