现代医院2025，Vol.25Issue(10)：1532-1534,1538,4.DOI:10.3969/j.issn.1671-332X.2025.10.013
全周期病案质量管理模式实践探索
Practice and exploration of a full-cycle medical record quality management model
袁燕 1卢彦冰 1卢建军 1熊莺1
作者信息
- 1. 中山大学附属第一医院 广东 广州 510080
- 折叠
摘要
Abstract
Objective To explore effective management methods for improving the efficiency of medical record quality control and enhancing medical record quality.Methods Based on a medical record quality control system,a full-cycle medical record quality management model was constructed,encompassing"pre-task reminders,real-time quality control during treatment,in-hospital process control,submission verification upon discharge,post-discharge terminal quality control,and re-verification af-ter archiving."Results Medical records achieved 100％quality control,and their quality significantly improved.The defect rate of medical record front pages and the delayed writing rate of surgical records in the hospital's discharged medical records continued to decline in the year before system implementation,the first year after implementation,and the second year after im-plementation.The 3-day retrieval rate of medical records increased significantly in the first year after implementation,with statis-tically significant differences in all three indicators(front page defect rate:x2=114.966,P＜0.001;delayed writing rate of sur-gical records:x2=8 056.614,P＜0.001;3-day retrieval rate:x2=798.201,P＜0.001).Conclusion The full-cycle medi-cal record management model based on a quality control system can effectively improve medical record quality and enhance man-agement efficiency.Future efforts should focus on integrating continuously optimized AI technology to strengthen system perform-ance.关键词
全周期管理/病历质控/质控系统/质量管理Key words
Full-cycle management/Medical record quality control/Quality control system/Quality management分类
医药卫生引用本文复制引用
袁燕,卢彦冰,卢建军,熊莺..全周期病案质量管理模式实践探索[J].现代医院,2025,25(10):1532-1534,1538,4.
