| 朱亚南1 刘承业2 郑玉建1 顾杰2 兰建忠2.某二级医院住院病历中不良事件风险评估的应用与研究[J].,2012,12(13):2557-2563 |
| 某二级医院住院病历中不良事件风险评估的应用与研究 |
| Research on Risk Assessment of Adverse Events in the QualityControl of Medical Records |
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| DOI： |
| 中文关键词: 住院病历 病历质量 不良事件 风险评估 |
| 英文关键词: Hospital records Medical quality Adverse events Risk assessment |
| 基金项目: |
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| 中文摘要: |
| 目的：通过病历中发生的不良事件及其风险度来评价病历质量，目的为加强病历环节和细节的质控，减少或杜绝病历中不
良事件的发生，提高病历书写质量，保证医疗安全，减少医疗纠纷。方法：随机抽查2007-2010 年某二级医院住院病历4837 份，对
其进行不良事件风险评估，对病历的终末质量和环节质量进行综合评价分析，找出影响医疗质量的相关联因素。结果：通过对某
二级医院2007-2010 年随机抽查的终末病历和病房中运行病历的不良事件风险评估，数据经过统计学处理后P 值＜0.01，说明总
的病历中不良事件发生率年度间逐年减少，有极为显著的差别，证明此种病历评价方法切实可行。结论：病历中不良事件风险评
估，是减少病历中不良事件发生的有效办法，可以消除病历书写中存在的医患矛盾和医疗纠纷隐患。 |
| 英文摘要: |
| Objective: Through medical records in the incidence of adverse events and the risk to evaluate the quality of medical
records, for the purpose of strengthening medical record links and details of quality control, reduce or prevent the medical record in the
occurrence of adverse events, improve the quality of medical records, ensure medical safety, reduce medical disputes. Methods: Random
sampling from 2007 to 2010, two levels of a hospital inpatient records of 4837, its adverse events in risk assessment, the final quality of
medical record and link quality comprehensive evaluation and analysis, find out the influence of the associated factors of medical quality.
Results: Through the two levels of a hospital in 2007~2010 random terminal medical record and ward running records for adverse events
in risk assessment, data through statistical processing of P value < 0.01, description of the total records in the incidence of adverse events
between year decreased year by year, with extremely significant difference, proving that this kind of patient evaluation the method is
practical and feasible. Conclusion: The case histories of adverse events in risk assessment, is to reduce the occurrence of adverse events
in a case of effective measures, can eliminate the medical record writing in the presence of the doctor-patient contradiction and potential
medical disputes. |
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