本文選題：病歷 + 質(zhì)量　； 參考：《第二軍醫(yī)大學》2017年碩士論文

【摘要】：病歷的作用和重要性隨著時代的進步發(fā)展,日益凸顯。良好的病歷質(zhì)量不僅能推動醫(yī)院醫(yī)療、教學、科研的發(fā)展,更在醫(yī)保付費、保險報銷、法律憑證、DRGs推廣等方面發(fā)揮重大作用。然而當前的病歷質(zhì)量并不能完全滿足社會和醫(yī)學發(fā)展對其提出的新要求。主流的病歷質(zhì)量控制方法也有一定局限性,缺乏相應的責任落實保障機制以確保質(zhì)控效果。研究目的本課題以提高病歷質(zhì)量,促進內(nèi)涵建設為導向,針對當前病歷質(zhì)量控制工作易受干擾,工作質(zhì)量無法保障的難題,旨在通過兩級隨機盲態(tài)模式的設計,建立科學嚴謹?shù)牟v質(zhì)控工作模式和責任落實保證機制,以優(yōu)化病歷檢查,完善工作監(jiān)管,構(gòu)建公正、公平、公開的質(zhì)控工作環(huán)境,提高質(zhì)控工作效能,同時借助責任化、常態(tài)化的質(zhì)控模式,促進各科室抓好源頭,持續(xù)改進病歷書寫質(zhì)量。另一方面,結(jié)合工作需要,設計開發(fā)病歷質(zhì)控操作平臺及信息發(fā)布系統(tǒng),以提升質(zhì)控工作效率,統(tǒng)一操作標準,優(yōu)化病歷整改流程,規(guī)范數(shù)據(jù)生成,減少人為因素造成的評價偏倚。研究方法和內(nèi)容本研究通過對文獻回顧、頭腦風暴、專家訪談等方法,掌握當前醫(yī)療機構(gòu)病歷質(zhì)量現(xiàn)狀及主流病歷質(zhì)控方法,分析發(fā)現(xiàn)其中的缺陷不足,結(jié)合某醫(yī)療機構(gòu)自身實踐經(jīng)驗,構(gòu)建一套以責任落實保障機制為核心的兩級隨機盲態(tài)化的病歷質(zhì)控模式,通過重組工作團隊,轉(zhuǎn)變工作方法,調(diào)整任務分工,規(guī)范信息發(fā)布,優(yōu)化病歷整改以及結(jié)果雙盲抽檢,問題反饋申訴,內(nèi)涵優(yōu)化評價,考核績效掛鉤等方法,優(yōu)化團隊結(jié)構(gòu),強化責任落實,提高質(zhì)控效能,構(gòu)建一個公平、公正、公開的質(zhì)控環(huán)境。同時,為提高病歷質(zhì)控效能,與軟件公司合作開發(fā)醫(yī)院住院病歷質(zhì)控操作平臺及信息發(fā)布系統(tǒng),以實現(xiàn)質(zhì)控工作高效,信息反饋及時,參與互動頻繁,資料生成規(guī)范,統(tǒng)計查詢流暢。最后,選取江蘇省某三甲醫(yī)院為試點,對構(gòu)建的理論模式和信息系統(tǒng)展開實地應用,檢驗理論效果,并根據(jù)運行情況,提出整改意見和完善方向,最終實現(xiàn)“抓好環(huán)節(jié),強化終末,迅速反饋,及時整改,提高內(nèi)涵”的目的。研究結(jié)果1.新質(zhì)控模式實施后,與2016年1月份病歷質(zhì)量同比發(fā)現(xiàn),2017年1月份終末病歷總體甲級病案率由90.6%上升至95.6%(P0.05),甲級病案率低于90%的病區(qū)數(shù)由13個降至5個(P0.05),嚴重缺陷病歷由4例降至0例,病歷全部及時歸檔。2.對一般缺陷情況進行分析發(fā)現(xiàn),病程記錄和基本規(guī)則輔助檢查方面問題是內(nèi)外科系終末病歷問題共同的高發(fā)區(qū)。病程記錄問題及入院記錄問題是內(nèi)外科系環(huán)節(jié)病歷問題的高發(fā)區(qū)。病程記錄問題是環(huán)節(jié)和終末病歷問題的共同高發(fā)區(qū)。3.對病歷內(nèi)涵質(zhì)量進行分析發(fā)現(xiàn),“缺陷類別”問題主要集中在“作為不當”和“不作為”,“作為不當”占絕大比例�！叭毕莺蠊悇e”問題主要集中在“一般侵犯經(jīng)濟利益”。4.從檢查人員工作考核情況來看,經(jīng)過醫(yī)院的針對性培訓,檢查人員能勝任質(zhì)控工作,圓滿完成任務,但還有改進空間。結(jié)論1.兩級隨機盲態(tài)化的質(zhì)控模式提高了病歷甲級病案率,降低了乙級、丙級病案率及病歷缺陷率,加快了病歷返修歸檔速度。此外,對病歷內(nèi)涵質(zhì)量的質(zhì)控評價也步入正軌,促進了病歷內(nèi)涵質(zhì)量提升,有效引導和規(guī)范了醫(yī)護人員的診療操作。2.新模式彌補了原先質(zhì)控隊伍人手不足,工作壓力大,人員專業(yè)結(jié)構(gòu)、分工不合理,檢查效率低下的局面,提升了隊伍執(zhí)行任務的科學性。3.形成了人人能負責、敢負責、必須負責的質(zhì)控環(huán)境,減少了人情等因素的干擾,確保工作公正公平、保質(zhì)保量完成。同時,構(gòu)建了一個溝通迅捷,反饋及時,操作有序,整改規(guī)范的病歷質(zhì)控管理閉合路徑,提高了工作效率。該質(zhì)控模式的實施,為解決當前病歷檢查工作質(zhì)量無法保證,質(zhì)控專家不受重視,質(zhì)控工作易受干擾等問題找到了一條有效的解決途徑,并且將病歷內(nèi)涵質(zhì)量也納入質(zhì)控范圍,有效促進了病歷質(zhì)量和內(nèi)涵水平的提升。同時,該模式對醫(yī)療機構(gòu)的硬件、軟件要求相對較低,值得嘗試推廣。推行該模式時要注意整體把握,重視環(huán)節(jié)質(zhì)量,細化內(nèi)涵評價,要善于利用信息化手段,同時做好教育培訓,抓好病歷書寫源頭,促進醫(yī)院文化形成。
[Abstract]:The role and importance of the medical records are becoming more and more important with the progress of the times. The good medical record quality can not only promote the development of hospital medical treatment, teaching and scientific research, but also play an important role in medical insurance pay, insurance reimbursement, legal voucher and DRGs promotion. However, the current medical record quality can not fully meet the development of society and medicine. New requirements. The mainstream medical record quality control method also has some limitations, the lack of corresponding responsibility implementation guarantee mechanism to ensure quality control effect. The purpose of the research is to improve the quality of the medical records, promote the connotation construction, and aim at the difficult problems of the current medical record quality control work, which are easily disturbed and the work quality can not be guaranteed. After the design of the two level random blind mode, a scientific and rigorous medical record quality control work mode and responsibility implementation guarantee mechanism are established to optimize the medical record inspection, improve the work supervision, build a fair, fair and open quality control work environment, improve the quality control work efficiency, and use the responsibility assignment and the normalization quality control mode, and promote the various departments to grasp the source well. On the other hand, the quality control operation platform and information publishing system are designed and developed to improve the efficiency of the quality control, the unified operation standard, the optimization of the medical record rectification process, the standardization of the data generation and the reduction of the evaluation bias caused by human factors. Review, brainstorming, expert interview and other methods, grasp the current medical records quality status and the mainstream medical record quality control method, analyze the defects and find out the defects. Combining with the practical experience of a medical institution, a set of two level random blind medical record quality control model with the responsibility implementation guarantee mechanism is constructed, and the reorganization work is carried out. The team, changing the work method, adjusting the task division, standardizing the information release, optimizing the medical record rectification and the double blind test, the problem feedback appeals, the connotation optimization evaluation, the performance linking and so on, optimize the team structure, strengthen the responsibility implementation, improve the quality control efficiency, construct a fair, just and open quality control environment. At the same time, in order to improve the disease, to improve the disease. In order to realize the high efficiency of the quality control work, the information feedback is timely, the participation of the information is frequent, the data is generated and the statistical query is fluent. Finally, a three a medical hospital in Jiangsu province is selected as the pilot, and the theoretical model and information system of the construction are carried out. Field application, test the theoretical effect, and according to the operation situation, put forward rectification opinions and improvement direction, finally realize the goal of "grasp the link, strengthen the end, feedback quickly, improve the connotation in time, improve the connotation". After the implementation of the 1. new quality control model of the research results, it was found on the same period of the medical records in January of 2016, and the final medical records of January 2017 were overall first grade. The rate of medical records increased from 90.6% to 95.6% (P0.05). The number of medical records below 90% was reduced from 13 to 5 (P0.05), and 4 cases were reduced from 4 cases to 0 cases, and all the cases were analyzed by.2.. The problem of record of the disease and the record of admission are the high incidence areas of the internal and external records of the Department of internal and external sciences. The problem of the record of the disease is the analysis of the quality of the medical record in the common high incidence area of the link and the end case history. The problem of "defect category" is mainly concentrated on "misconduct" and "Inaction", "as a misfit". The problem of "defect consequences category" is mainly focused on the "general violation of economic interests".4. from the inspection of the inspectors. Through the targeted training of the hospital, the inspectors can be qualified for quality control work and complete the task satisfactorily, but there is room for improvement. Conclusion the quality control model of 1. level two level random blindness improves the medical record. The grade a medical record rate has reduced the grade B, the rate of class C case and the rate of medical record defect, quickened the speed of medical record repair and filing. In addition, the quality control evaluation of medical records also stepped into the right track, promoted the quality of the medical record and improved the quality of medical records, and effectively guided and standardized the new.2. model of medical and nursing staff to make up for the shortage of the original quality control team. As a result of high pressure, professional structure, unreasonable division of labor and low efficiency, the scientific.3. of the team is responsible, responsible and responsible for the quality control environment, reducing the interference of factors such as human feelings, ensuring fair and fair work and completing the quality and quantity. At the same time, a communication and rapid communication is built. The implementation of the quality control model can not guarantee the quality of the current medical record inspection, the quality control experts are not paid attention to, and the quality control work is easily disturbed by the quality control, and the quality of the medical record is also included in the quality control. The scope of quality control has effectively promoted the improvement of medical record quality and connotation level. At the same time, the model is relatively low in hardware and software requirements for medical institutions, and it is worth trying to popularize. When the model is implemented, we should pay attention to the overall grasp, attach importance to the quality of the link, refine the connotation evaluation, make good use of information means, do a good job in education and training, and grasp the medical record. To write the source to promote the formation of the hospital culture.

【學位授予單位】：第二軍醫(yī)大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R197.323

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