基于根因分析法管理措施對電子病案首頁管理中的應(yīng)用效果

何奕

[摘要] 目的 探討基于根因分析法管理措施對電子病案首頁管理中的應(yīng)用效果。方法 該院選擇2018年3—9月，實施根因分析法管理前半年的5 020份電子病案設(shè)置為對照組，研究組為實施根因分析法管理后半年的5 020份病案。分析對照組病案首頁問題，統(tǒng)計對照組所有超期未歸檔的原因，比較實施根因分析法管理前后，兩組在病案的歸檔率情況。結(jié)果 對照組病案超期未歸檔的原因中占比最大為：病理報告單延遲歸檔占比26.97%;因患者轉(zhuǎn)科，科室病案信息不完善占比22.53%;檢驗報告單延遲歸檔占比14.43%。實施根因分析法管理后，研究組的普通的病案3 d歸檔率為（81.30%）明顯高于對照組的病案3 d歸檔率（69.18%），差異有統(tǒng)計學(xué)意義（P<0.05）。研究組死亡病案7 d歸檔率明顯高于對照組（93.33% vs 58.82%），差異有統(tǒng)計學(xué)意義（P<0.05）。結(jié)論 基于根因分析法管理措施對電子病案首頁管理，可顯著提高電子病案的回收率，降低電子病案的缺陷，顯著提升電子病案首頁的質(zhì)量，值得使用及推廣。

[關(guān)鍵詞] 根因分析法;電子病案;首頁;病案管理

[中圖分類號] R19 [文獻(xiàn)標(biāo)識碼] A [文章編號] 1672-5654（2020）02（a）-0041-03

Application Effect of Management Measures Based on Root Cause Analysis in Homepage Management of Electronic Medical Records

HE Yi

Information Network Center， People's Hospital of Yunmeng County， Yunmeng， Hubei Province， 432500 China

[Abstract] Objective To explore the application effect of management measures based on root cause analysis method on the management of the front page of electronic medical records. Methods From March to September 2018， the hospital selected 5 020 electronic medical records in the first half of the year to implement the root cause analysis method as the control group， and the research group was 5 020 medical records in the first half of the year to implement the root cause analysis method. Analyze the problem of the first page of the medical records of the control group， and calculate all the reasons for the overdue unfiled in the control group， and compare the archiving rate of the medical records between the two groups before and after implementing the root cause analysis method. Results The largest proportion of the reasons for the undocumented medical records in the control group were： delayed filing of pathological reports accounted for 26.97%; incomplete departmental medical records accounted for 22.53% due to patient transfer; and delayed filing of test reports accounted for 14.43%. After implementing the root cause analysis method， the three-day archiving rate of common medical records in the study group （81.30%） was significantly higher than that of the control group （69.18%）， which was statistically significant （P<0.05）. The 7-day filing rate of death cases in the study group was significantly higher than that in the control group （93.33% vs 58.82%）， and the difference was statistically significant（P<0.05）. Conclusion The management of electronic medical records homepage based on the root cause analysis method can significantly improve the recovery rate of electronic medical records， reduce the defects of electronic medical records， and significantly improve the quality of electronic medical records homepages. It is worth using and promoting.

[Key words] Root cause analysis method; Electronic medical record; Homepage; Medical record management

電子病案是醫(yī)院實行管理的基礎(chǔ)，病案管理的任務(wù)主要包括制定規(guī)章制度、統(tǒng)計分析、集中病案、歸檔整理、供應(yīng)調(diào)閱、保管復(fù)印[1]。能為科研、醫(yī)療、教學(xué)等提供病案信息服務(wù)，通過對數(shù)據(jù)進(jìn)行統(tǒng)計分析，為醫(yī)院提供統(tǒng)計報表及信息，對疾病的預(yù)防、治療都有著重要性作用[2]。電子病案首頁的管理能體現(xiàn)出一個醫(yī)院的總體醫(yī)療質(zhì)量，也是評估醫(yī)院醫(yī)療水平的主要因素。但因病案首頁填寫往往涉及到多個部門科室，在實際管理中常出現(xiàn)信息缺失、歸檔不及時。為提高病案首頁管理的質(zhì)量，實行根因分析法管理措施對電子病案首頁進(jìn)行管理。根因分析法是一種循環(huán)結(jié)構(gòu)化處理問題的方法，可分析并找出超期未歸檔的原因，并針對查找出的問題進(jìn)行解決[3]。……