面向臨床路徑的病案質(zhì)量監(jiān)控體系研究
發(fā)布時(shí)間：2019-02-12 23:34
【摘要】：目的 在文獻(xiàn)分析和實(shí)證調(diào)查的基礎(chǔ)上，吸取病案質(zhì)量監(jiān)控的既有研究經(jīng)驗(yàn)，并根據(jù)問(wèn)卷調(diào)查、知情人訪談、德?tīng)柗品ǖ确椒ㄌ岢雠R床路徑的病案質(zhì)量監(jiān)控內(nèi)容，制定科學(xué)的監(jiān)控方法、監(jiān)控流程以及監(jiān)控組織和制度，共同形成一套完善的面向臨床路徑的病案質(zhì)量監(jiān)控體系，達(dá)到規(guī)范臨床路徑的醫(yī)療行為、提高臨床路徑的病案質(zhì)量，使臨床路徑的制定和執(zhí)行者能夠更好地利用病案信息于臨床路徑，進(jìn)而促使我國(guó)臨床路徑的病案書(shū)寫(xiě)達(dá)到規(guī)范化的目的。 方法 采用定量研究與定性研究相結(jié)合的方法進(jìn)行分析。主要方法包括：（1）文獻(xiàn)復(fù)習(xí)法：利用中外知名數(shù)據(jù)庫(kù)以及搜索引擎，，檢索和查詢國(guó)內(nèi)外有臨床路徑與病案質(zhì)量監(jiān)控的理論、方法及研究成果；（2）現(xiàn)場(chǎng)調(diào)查：通過(guò)問(wèn)卷調(diào)查、知情人訪談等方法對(duì)醫(yī)師的病案書(shū)寫(xiě)、醫(yī)院的病案質(zhì)量監(jiān)控方法、流程、應(yīng)用效果和存在問(wèn)題、進(jìn)行調(diào)查與分析；（3）數(shù)理統(tǒng)計(jì)法：運(yùn)用描述性統(tǒng)計(jì)方法分析病歷書(shū)寫(xiě)情況和病案的質(zhì)量監(jiān)控現(xiàn)狀；（4）專家咨詢法：運(yùn)用專家咨詢法提煉出出臨床路徑的病案質(zhì)量監(jiān)控內(nèi)容。 結(jié)果 （1）利用問(wèn)卷調(diào)查、知情人訪談和文獻(xiàn)研究了解到：目前的尚未有醫(yī)院開(kāi)展面向臨床路徑的病案質(zhì)量監(jiān)控，醫(yī)師和管理人員對(duì)臨床路徑的了解較少，對(duì)病歷書(shū)寫(xiě)規(guī)范和ICD編碼的熟悉程度也不夠；現(xiàn)醫(yī)院多采用四級(jí)病案質(zhì)量監(jiān)控，但存在不重視環(huán)節(jié)質(zhì)控，病歷各部分書(shū)寫(xiě)的時(shí)限不能被監(jiān)控，病歷出科前沒(méi)有重點(diǎn)進(jìn)行內(nèi)涵質(zhì)量控制，監(jiān)控力度不夠，獎(jiǎng)懲執(zhí)行不嚴(yán)，監(jiān)控效果不明顯等問(wèn)題。 （2）運(yùn)用德?tīng)柗品�，以急性心肌梗死為例，�?jīng)過(guò)兩輪專家咨詢確定了在病案首頁(yè)、出院（死亡）記錄、入院記錄（或再次入院記錄）、病程記錄、醫(yī)囑單及輔助檢查單五個(gè)維度下的16條面向臨床路徑的病案質(zhì)量監(jiān)控具體內(nèi)容，并加入到病歷質(zhì)量考核評(píng)分標(biāo)準(zhǔn)中。 （3）確定了醫(yī)院病案質(zhì)量委員會(huì)的組織人員及其工作職責(zé)，提出了面向臨床路徑的病案質(zhì)量監(jiān)控方法和流程，重點(diǎn)在于責(zé)任落實(shí)到每一層人員以及每個(gè)環(huán)節(jié)的質(zhì)控要點(diǎn)，制定了病案質(zhì)量檢查的獎(jiǎng)懲制度和評(píng)分標(biāo)準(zhǔn)。構(gòu)建了一套完整的面向臨床路徑的病案質(zhì)量監(jiān)控體系。 結(jié)論 （1）目前醫(yī)院的病案質(zhì)量監(jiān)控效果不佳，醫(yī)師和病案人員對(duì)臨床路徑與病歷書(shū)寫(xiě)的重視程度和相關(guān)規(guī)范的了解程度不夠，對(duì)面向臨床路徑的病案質(zhì)量監(jiān)控規(guī)范的研究十分必要。 （2）提出了對(duì)提高臨床路徑的病案質(zhì)量的幾條建議：加強(qiáng)對(duì)臨床醫(yī)師的培訓(xùn)；提高病案管理人員的專業(yè)素質(zhì)；制定臨床路徑的病案質(zhì)量監(jiān)控標(biāo)準(zhǔn)。
[Abstract]:Objective on the basis of literature analysis and empirical investigation, to draw on the existing research experience of medical record quality monitoring, and to put forward the contents of medical record quality monitoring based on questionnaire, insiders interview, Delphi method and so on. To establish a scientific monitoring method, monitoring process, monitoring organization and system, to form a set of perfect medical record quality monitoring system for clinical pathway, to standardize the medical behavior of clinical pathway, and to improve the quality of clinical path. The establishment and implementation of the clinical pathway can make better use of the medical record information in the clinical pathway, and promote the writing of the medical record of the clinical pathway in our country to achieve the purpose of standardization. Methods quantitative analysis and qualitative analysis were used. The main methods are as follows: (1) Literature review: using well-known databases and search engines at home and abroad to retrieve and query the theories, methods and research results of quality monitoring of clinical pathway and medical records at home and abroad; (2) On-site investigation: investigation and analysis of physician's medical record writing, hospital's medical record quality monitoring method, process, application effect and existing problems by means of questionnaire investigation, insiders interview and so on; (3) Mathematical statistics: the descriptive statistical method is used to analyze the status quo of medical record writing and the quality control of medical record; (4) expert consultation method is used to extract the content of medical record quality control of clinical pathway. Results (1) by using questionnaires, insiders interviews and literature studies, it was found that no hospital has carried out medical record quality monitoring for clinical pathway at present, and doctors and administrators have little understanding of clinical pathway. Not enough familiarity with the standard of medical record writing and ICD code; At present, most hospitals adopt the quality control of medical records at four levels, but they do not attach importance to the quality control of links, the time limit for the writing of each part of the medical records cannot be monitored, the medical records do not focus on the connotation quality control before the medical records leave the department, the monitoring efforts are not enough, the rewards and punishments are not strictly executed. The monitoring effect is not obvious and so on. (2) using Delphi method, taking acute myocardial infarction as an example, two rounds of expert consultation were used to determine the records of discharge (death), hospital admission (or re-admission), course of disease, and the first page of the medical record. Under the five dimensions of the doctor's order list and the auxiliary examination sheet, 16 medical record quality monitoring contents oriented to the clinical path were included in the quality assessment and scoring standard of the medical record. (3) the organization and responsibility of the hospital medical record quality committee are determined, and the method and process of medical record quality monitoring oriented to clinical path are put forward. The key points of quality control for each layer of personnel and each link are put forward, and the emphasis is on the implementation of the responsibility to each level of personnel and the key points of quality control in each link. The system of rewards and punishments for medical record quality examination and the scoring standard were established. A complete medical record quality monitoring system for clinical pathway was constructed. Conclusion (1) at present, the quality control of medical records in hospitals is not good, and doctors and medical records personnel pay less attention to clinical path and medical record writing and know less about relevant norms. It is necessary to study the quality monitoring standard of medical record oriented to clinical pathway. (2) several suggestions are put forward to improve the quality of the medical record of the clinical pathway: strengthening the training of the clinicians, improving the professional quality of the medical record management personnel, and formulating the quality control standard of the medical record of the clinical pathway.
【學(xué)位授予單位】：華中科技大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R197.323
本文編號(hào)：2420909
[Abstract]:Objective on the basis of literature analysis and empirical investigation, to draw on the existing research experience of medical record quality monitoring, and to put forward the contents of medical record quality monitoring based on questionnaire, insiders interview, Delphi method and so on. To establish a scientific monitoring method, monitoring process, monitoring organization and system, to form a set of perfect medical record quality monitoring system for clinical pathway, to standardize the medical behavior of clinical pathway, and to improve the quality of clinical path. The establishment and implementation of the clinical pathway can make better use of the medical record information in the clinical pathway, and promote the writing of the medical record of the clinical pathway in our country to achieve the purpose of standardization. Methods quantitative analysis and qualitative analysis were used. The main methods are as follows: (1) Literature review: using well-known databases and search engines at home and abroad to retrieve and query the theories, methods and research results of quality monitoring of clinical pathway and medical records at home and abroad; (2) On-site investigation: investigation and analysis of physician's medical record writing, hospital's medical record quality monitoring method, process, application effect and existing problems by means of questionnaire investigation, insiders interview and so on; (3) Mathematical statistics: the descriptive statistical method is used to analyze the status quo of medical record writing and the quality control of medical record; (4) expert consultation method is used to extract the content of medical record quality control of clinical pathway. Results (1) by using questionnaires, insiders interviews and literature studies, it was found that no hospital has carried out medical record quality monitoring for clinical pathway at present, and doctors and administrators have little understanding of clinical pathway. Not enough familiarity with the standard of medical record writing and ICD code; At present, most hospitals adopt the quality control of medical records at four levels, but they do not attach importance to the quality control of links, the time limit for the writing of each part of the medical records cannot be monitored, the medical records do not focus on the connotation quality control before the medical records leave the department, the monitoring efforts are not enough, the rewards and punishments are not strictly executed. The monitoring effect is not obvious and so on. (2) using Delphi method, taking acute myocardial infarction as an example, two rounds of expert consultation were used to determine the records of discharge (death), hospital admission (or re-admission), course of disease, and the first page of the medical record. Under the five dimensions of the doctor's order list and the auxiliary examination sheet, 16 medical record quality monitoring contents oriented to the clinical path were included in the quality assessment and scoring standard of the medical record. (3) the organization and responsibility of the hospital medical record quality committee are determined, and the method and process of medical record quality monitoring oriented to clinical path are put forward. The key points of quality control for each layer of personnel and each link are put forward, and the emphasis is on the implementation of the responsibility to each level of personnel and the key points of quality control in each link. The system of rewards and punishments for medical record quality examination and the scoring standard were established. A complete medical record quality monitoring system for clinical pathway was constructed. Conclusion (1) at present, the quality control of medical records in hospitals is not good, and doctors and medical records personnel pay less attention to clinical path and medical record writing and know less about relevant norms. It is necessary to study the quality monitoring standard of medical record oriented to clinical pathway. (2) several suggestions are put forward to improve the quality of the medical record of the clinical pathway: strengthening the training of the clinicians, improving the professional quality of the medical record management personnel, and formulating the quality control standard of the medical record of the clinical pathway.
【學(xué)位授予單位】：華中科技大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R197.323
【引證文獻(xiàn)】
相關(guān)期刊論文 前1條
1 楊凌燕;;病案信息化過(guò)程中質(zhì)量監(jiān)控及風(fēng)險(xiǎn)防范[J];現(xiàn)代儀器與醫(yī)療;2013年05期
本文編號(hào)：2420909
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