managerial communication quality control of medical records quality of medical records
2015年南京大学医院管理研究所课题（NDYG2015016）
目的：调查江苏某三甲医院在病案质控模式转变后病案质量的变化情况，分析不同沟通方式对病案质量的影响，为病案质控管理工作提供一定的思路。方法：实验组为2018年3—9月多维沟通方式下在职医师参与质控的病案1 897份，对照组为2017年3—9月孤立型沟通方式下退休专家质控的病案1 189份，对比两组病案的甲级率、乙级率、丙级率情况。结果：与对照组相比，实验组甲级病案率为96.47%，乙级病案率为2.63%，丙级病案率为0.896%，实验组甲级率明显高于对照组，乙级率和丙级率低于对照组，抽取病案数量占出院病案比率提高了0.89%，差异均具有统计学意义。结论：四级质控体系完善后，在职医师参与病案质控管理，可以建立线上和线下双向反馈机制，形成多维沟通方式，有利于充分调动临床医生参与病历质量管理的积极性，推动病案质控管理工作，提高病历质量。
Objective：To analyze the effect of application of multi-dimension communication on quality of medical records in a grade A tertiary hospital in Jiangsu Province. Methods：A total of 1 897 medical records under the quality control management receiving multi-dimension communication were enrolled in the experimental group，and a total of 1 189 medical records under the quality control management receiving solitary communication were enrolled as control group. the level A rate，level B rate and level C rate were recorded and compared between experimental group and control group. Results：The quality of medical records in the experimental group was significantly better than that in the control group evidently. Conclusions：With the improvement of four-level quality control system，the application of quality control by physicians is helpful to improve the four-level quality control system. Building the two-way feedback mechanism and multi-dimension communication channels are beneficial for inspiring the participation of clinical doctors，which could improve the quality of medical records.