病历质量管理系统在环节病历检查中的应用

摘要

目的:探讨百泰网络病历质量管理系统V2.5在医院环节病历质控中的应用效果.方法:自2012年1月开始,医院运用百泰网络病历质量管理系统V2.5对住院电子病案进行实时监控,对比系统使用前后1 a终末病历的平均甲级病历率、病历缺陷率、病历返修率.结果:相对于2011-2012年间的终末病历资料,2012-2013年实施环节质控后,病历甲级病案率有显著提高,而病历缺陷率及病历返修率均呈现下降,并具有统计学意义(P＜0.05).结论:借助第三方质控软件,建立三级质控新模式,强化环节质控过程,对提高整体病案质量有促进作用.%Objective To explore the effect of Baitai Medical Records Quality Management System(BMRQMS)V2.5 on Link medical records quality control of the 150th Hospital of the PLA.Methods The rates for Grade A medical record,defect and repair were compared before and after the introduction of BMRQMS in January 2012.Results The medical records during 2011 were compared with those during 2012,whose rate for Grade A was significantly higher,and rates for defect and repair were statistically lower,with P＜0.05.Conclusion It's important for the quality promotion of the medical records to introduce the thir-party software,establish three-level quality control mode and strengthen the procedure.