oncology specialty medical records quality control point quality control system
江苏省肿瘤医院质控项目（ZG201703）
目的：探讨建立具有肿瘤专科医院特色的运行病历质量管理体系，提高医院病案质量和管理水平。方法：通过抽查运行病历对质控实施前后的病案质量进行分析，2018年运行病历检查缺陷率较2017年下降5.99%。结果：通过设置电子化质控点、病案书写培训、DRG软件的应用和完善病案质控方案等可改善病案质量。结论：建立符合肿瘤专科特点的运行病历质控体系，要综合考虑运行病历流程中的各个关键环节，加强质控和引导，促进医院精细化管理。
Objective：To study the establishment of a refined quality management system for medical records with the characteristics of oncology hospitals，and to improve the quality management level of medical records in hospitals. Methods：The quality of medical records before and after the implementation of refined quality control management system was analyzed through spot check of operational medical records. Results：The defect rate of operational medical records in 2018 was 5.99%，which was lower than that in 2017. The quality of medical records could be improved by setting up electronic quality control points，carrying out training of medical records writing，implementing DRG software and improving the quality control scheme of medical records. Conclusions： The establishment of the quality control system of medical records in oncology hospitals should consider the links of medical records supervision，strengthen quality control and guidance，and promote the refined management of hospitals.