医师轮转病案室对病案质量的影响

目的探讨病案室轮转制度对临床医师书写病案质量的影响。方法对比临床医师参加病案室轮转前后书写病历的质量,统计分析该制度实施前后的临床医师病案质量变化。具体方法是:所有新参加工作的临床医师,经统一组织、安排后,在病案复核室轮转工作至少3个月,主要工作是审核相关临床科室的出院病案,包括出院病案的质量、病案记录中涉及患者手术、有创操作等的签字,以及知情同意书的签字等病案法律法规等内容。同时,每位参与病案室轮转的医师还就《黑龙江省病历书写规范》进行理论学习。以理论指导病案室的病案审核工作,以实际工作加深轮转医师对病案质量、病案法律法规等相关内容的理解与掌握。结果临床医师参与病案室轮转前后病历书写规范合格率(81.7%VS.95.6%)、病案法律法规知晓率(79.7%VS.96.8%)、病案知识测验平均分(83.7±5.6 VS.95.2±3.7)、病案缺陷率(21.5%VS.9.7%)、重度病案缺陷率(12.3%VS.4.1%)、归档前病案返修率(13.7%VS.4.6%)、医疗纠纷涉及病案错误比率(66.7%VS.26.7%)等指标均有统计学意义。结论临床医师参与病案室轮转可显著改进其书写的病案质量。

The Impact of Rotation at Medical Record Department to the Quality of the Medical Records

To investigate the impact of rotation at the medical records department on the quality of medical records that written by clinicists. Methods Make a comparison on the quality of medical records written by clinicists before and after their ro- tation at medical record department, and statistical analysis were taken to confirm the change of the medical records quality before and after the implementation of the rotation rules in medical record department. The specific method is to organise all the new clinicists in our hospital to rotate at medical records department for at least three months. Their work is to examine the medical records of patients leave our hospital from each related departments, such as the general quality, signatures involved operations, invasive process, in- formed consent as well as all the legal contents in medical records. At the same time, they should have theoretical studying according to ＂Written Norms of Medical Records of Heilongjiang＂, and then make theoretical direction to the examination. Through above practical work to strengthen the understanding and acquirement of medical records and related legal contents among clinicists. Results The percentage of qualified and standard medical records written by the clinicists who had finished the rotation at medical record de- partment （79.7% vs. 96.8% P 〈 0.001） ; the average score of test on medical record knowledge （83.7 vs. 95.2 P 〈 0.001） ; the defective rate of medical rccord （slight defect： 21.5% vs. 9.7% P〈0.001; the severe defect： 12.3% vs. 4.1% P〈0.001）; the percentage of medical records sent back for preserving as official files（ 13.7% vs. 4.6% P 〈 0. 001 ）; percentage of medical records fault involved in medical dispute（66.7% vs.26.7% P 〈 0.001）. Conclusion The quality of medical records written by the clinicists can be significantly improved after their rotation at medical record department.