精細化管理在準分子激光門診手術(shù)病歷管理中的應(yīng)用

陳容

[摘要] 目的 評價準分子激光門診手術(shù)病歷管理工作中應(yīng)用精細化管理的價值，從而提高手術(shù)病歷管理工作質(zhì)量。方法 在該院準分子激光門診手術(shù)病歷管理工作中落實精細化管理前2017年5月—2018年5月期間以及2018年6月—2019年6月管理后各隨機抽查門診手術(shù)病歷500份，總結(jié)精細化管理前后書寫不完整、涂改未簽字、整潔性差、報告單等病歷質(zhì)量以及手術(shù)前后放置混淆、使用后歸檔不及時、病歷遺失、缺頁缺項等病歷歸檔情況、病歷檔案管理人員績效考核合格率與考核評分。結(jié)果 精細化管理實施后對比實施前，書寫不完整、涂改未簽字等病歷質(zhì)量以及、缺頁缺項等病歷歸檔明顯改善，病歷檔案管理人員績效考核合格率、評分均明顯提高（P<0.05）。結(jié)論 準分子激光門診手術(shù)病歷管理工作中基于多種因素影響導(dǎo)致工作整體質(zhì)量下降，精細化管理的應(yīng)用可以成功提高病歷管理質(zhì)量，利于工作的有效、安全開展。

[關(guān)鍵詞] 精細化管理;分子激光門診手術(shù);病歷管理;病歷質(zhì)量

[中圖分類號] R473 [文獻標識碼] A [文章編號] 1672-5654（2020）02（c）-0023-03

[Abstract] Objective To evaluate the value of applying refined management in the management of medical records of excimer laser outpatient surgery， so as to improve the quality of surgical medical records management. Methods During the management of medical records of excimer laser outpatient surgery in the hospital， 500 random outpatient medical record were randomly selected from May 2017 to May 2018 and June 2018 to June 2019 after management. Summarize the incomplete writing before and after refined management， unsigned changes， poor cleanliness， poor quality of medical records such as report forms， confusion before and after surgery， untimely archiving after use， missing medical records， missing pages and missing items， and other records of medical records， performance of medical record file managers assessment pass rate and assessment score. Results After the implementation of refined management， compared with before implementation， the quality of medical records such as incomplete writing， altered and unsigned signatures， and medical records such as missing pages and missing items were significantly improved. The performance assessment qualification rate and scores of medical record file managers were significantly improved（P<0.05）. Conclusion The overall quality of the work is reduced due to various factors in the management of excimer laser outpatient surgery medical records. The application of refined management can successfully improve the quality of medical records management， which is conducive to the effective and safe development of the work.

[Key words] Refined management;Molecular laser outpatient surgery;Medical record management; Medical record quality

青光眼、白內(nèi)障、近視、遠視、散光、沙眼等均為眼科常見疾病，當前基于人們用眼習慣差、電子產(chǎn)品不斷出現(xiàn)等多種因素導(dǎo)致眼病患者明顯增多，多數(shù)眼科疾病以手術(shù)治療為主[1]。眼科疾病中準分子激光手術(shù)安全性高、預(yù)測性佳，所以具有廣泛應(yīng)用價值。準分子激光手術(shù)用時短，是門診常見術(shù)式。對于患者而言，病例質(zhì)量直接影響患者就診以及預(yù)后等情況[2]。手術(shù)病歷文字檔案主要存放于科室檔案室，而當前患者的增多、年限的增長導(dǎo)致病歷越來越多，進而導(dǎo)致了明顯的病歷質(zhì)量、保管問題，需強化手術(shù)病歷檔案管理工作[3]。……