应用出院记录量表评估某院儿科出院病案书写质量分析(1)
摘 要：目的 探讨提高临床医师出院记录书写质量的对策。方法 应用出院记录评分量表，对某院儿科医师在住院医师期间的出院病案进行量化评估，按照评价标准进行专项定量质控，将质控结果录入Excel表中进行统计分析。结果 按照出院记录评分量表分别对6名儿科医师担任第1～5年住院医师期间，每人每年各20份共600份出院记录进行评分，采用非参数检验对不同年资住院医师出院记录总分统计分析，除第4年组与第5年组差异无统计学意义(P>0.01)；其余各组间的平均轶的差异有统计学意义(P<0.01)。出院记录评分量表中16项书写内容逐项评分，专项均值低于3分的书写内容项目集中在：治疗经过、病情演变、住院期间用药及治疗期间药物更换说明。结论 出院记录量表为临床医师规范书写出院记录提供了参考标准，不同年资住院医师的出院记录书写质量均需亟待提高。
关键词：出院记录；书写；量化评分法
中图分类号：R197.323 文献标识码：B DOI：10.3969/j.issn.1006-1959.2018.22.005
, 百拇医药
文章编号：1006-1959(2018)22-0014-03
Application of Discharge Records Scale to Assess the Quality of Written Records of Pediatric Discharge in A Hospital
PAN Qiu-sha，YAN Shi-jun，SUN Yu
(Department of Pediatrics，the No.81 Hospital of the PLA，Nanjing 210002，Jiangsu，China)
Abstract：Objective To improve the writing quality of the pediatric discharge summaries. Methods The discharge records of pediatricians in a hospital were evaluated quantitatively by using the discharge summary quality assessment tool. The quality control was carried out according to the evaluation standard， and the quality control results were recorded into the Excel table for statistical analysis. Results According to the report of the discharged records， 6 pediatricians were rated as the 1th to 5th year resident， each 20 total of 600 discharge records per person per year， and the statistical analysis of the total score of the discharged records of different years of residency was performed by nonparametric test， the 4th and 5th year group was no statistically significant difference (P>0.01)，the difference in average anecdotes was statistically significant (P<0.01). The contents of 16 items in the discharge record assessment form were graded， and the items with a specific average of less than 3 were focused on： treatment， progression， medication during hospitalization， and drug replacement instructions during treatment. Conclusion The discharge summary quality assessment tool provides a reference standard for clinicians to write discharge. The quality of discharge records of residents with different seniority needs to be improved.
, 百拇医药
Key words：Discharge records；Writing；Quantitative scoring method
出院记录是对患者住院期间诊疗情况的全面总结，是医患沟通的桥梁，也是临床医师书写病案技能的集中体现。一份有效的出院记录，需要简明扼要准确反映患者住院期间的医疗信息，为患者后续诊疗提供有效的参考。目前，临床医师出院记录的书写主要由各科住院医师、实习医师在上级医师的审批下完成。由于缺乏出院记录书写质量管理的系统性培训，书写技巧主要来自于上级医师言传身教以及临床工作中的自我摸索。如何提高出院記录书写质量，减少因出院记录书写不规范而造成的不良事件，是每个临床医师在医疗实践工作中亟需解决的问题[1]。目前我国尚无出院记录书写的相关指南或建议，国内相关文献对出院记录的评估，也只是定性的统计分析，缺乏定量的有效评估资料。2017年澳大利亚病例质量管控部门提出了出院记录质量评估量表[2]，该量表的提出为我们规范出院小结的书写提供了借鉴。本研究应用该评估量表的相关内容，结合本科实际情况进行适当调整，回顾性评估某院6名儿科医师自2011年1月～2017年1月担任住院医师第1～5年期间出院记录病案书写质量，旨在通过对出院记录书写质量的回顾性调查，为后续提高出院记录的规范化书写提供有效参考。, http://www.100md.com(潘秋莎 颜世军 孙雨)
关键词：出院记录；书写；量化评分法
中图分类号：R197.323 文献标识码：B DOI：10.3969/j.issn.1006-1959.2018.22.005
, 百拇医药
文章编号：1006-1959(2018)22-0014-03
Application of Discharge Records Scale to Assess the Quality of Written Records of Pediatric Discharge in A Hospital
PAN Qiu-sha，YAN Shi-jun，SUN Yu
(Department of Pediatrics，the No.81 Hospital of the PLA，Nanjing 210002，Jiangsu，China)
Abstract：Objective To improve the writing quality of the pediatric discharge summaries. Methods The discharge records of pediatricians in a hospital were evaluated quantitatively by using the discharge summary quality assessment tool. The quality control was carried out according to the evaluation standard， and the quality control results were recorded into the Excel table for statistical analysis. Results According to the report of the discharged records， 6 pediatricians were rated as the 1th to 5th year resident， each 20 total of 600 discharge records per person per year， and the statistical analysis of the total score of the discharged records of different years of residency was performed by nonparametric test， the 4th and 5th year group was no statistically significant difference (P>0.01)，the difference in average anecdotes was statistically significant (P<0.01). The contents of 16 items in the discharge record assessment form were graded， and the items with a specific average of less than 3 were focused on： treatment， progression， medication during hospitalization， and drug replacement instructions during treatment. Conclusion The discharge summary quality assessment tool provides a reference standard for clinicians to write discharge. The quality of discharge records of residents with different seniority needs to be improved.
, 百拇医药
Key words：Discharge records；Writing；Quantitative scoring method
出院记录是对患者住院期间诊疗情况的全面总结，是医患沟通的桥梁，也是临床医师书写病案技能的集中体现。一份有效的出院记录，需要简明扼要准确反映患者住院期间的医疗信息，为患者后续诊疗提供有效的参考。目前，临床医师出院记录的书写主要由各科住院医师、实习医师在上级医师的审批下完成。由于缺乏出院记录书写质量管理的系统性培训，书写技巧主要来自于上级医师言传身教以及临床工作中的自我摸索。如何提高出院記录书写质量，减少因出院记录书写不规范而造成的不良事件，是每个临床医师在医疗实践工作中亟需解决的问题[1]。目前我国尚无出院记录书写的相关指南或建议，国内相关文献对出院记录的评估，也只是定性的统计分析，缺乏定量的有效评估资料。2017年澳大利亚病例质量管控部门提出了出院记录质量评估量表[2]，该量表的提出为我们规范出院小结的书写提供了借鉴。本研究应用该评估量表的相关内容，结合本科实际情况进行适当调整，回顾性评估某院6名儿科医师自2011年1月～2017年1月担任住院医师第1～5年期间出院记录病案书写质量，旨在通过对出院记录书写质量的回顾性调查，为后续提高出院记录的规范化书写提供有效参考。, http://www.100md.com(潘秋莎 颜世军 孙雨)