现代医院2024,Vol.24Issue(5) :733-736.DOI:10.3969/j.issn.1671-332X.2024.05.020

某三级专科医院2022年度细菌培养检查记录符合率调查分析

Analysis of the baseline investigation results of the conformity rate of bacterial culture examination records in a tertiary specialized hospital in 2022

郭可欣 童金英 罗阳 刘雨婷 李晓蓉 周鑫 胥丽丝 黄珺晨 田庆锷
现代医院2024,Vol.24Issue(5) :733-736.DOI:10.3969/j.issn.1671-332X.2024.05.020

某三级专科医院2022年度细菌培养检查记录符合率调查分析

Analysis of the baseline investigation results of the conformity rate of bacterial culture examination records in a tertiary specialized hospital in 2022

郭可欣 1童金英 1罗阳 1刘雨婷 1李晓蓉 1周鑫 1胥丽丝 1黄珺晨 1田庆锷1
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作者信息

  • 1. 湖南妇女儿童医院 湖南长沙 410006
  • 折叠

摘要

目的 通过对某三级专科医院细菌培养检查记录符合率基线进行调查分析,了解细菌培养检查病历书写现状,探讨提高细菌培养检查记录符合率的改进路径及相关措施.方法 根据《病案管理质量控制指标(2021年版)》要求,对2022年度细菌培养检查的6 317份病历进行回顾性分析.结果 医嘱执行率为100.00%,报告单完整率100.00%,病程记录率81.05%,结果分析率为33.07%,细菌培养检查记录符合率为33.07%.结论 进一步提高细菌培养检查记录符合率,提升病案内涵质量刻不容缓.

Abstract

Objective This paper aims to investigate and analyze the baseline conformity rate of bacterial culture exami-nation records in a tertiary specialized hospital.By doing this,this paper seeks to understand the current situation of medical re-cord writing of bacterial culture examination and explore the improvement path and relevant measures for enhancing the conformity rate of bacterial culture examination records.Methods According to the requirements of"Quality Control Index of Medical Re-cord Management(2021 Edition)",a retrospective analysis was conducted on 6 317 medical records that underwent bacterial culture examination in 2022.Results The execution rate of medical orders was 100.00%,the completeness rate of the report sheet was 100.00%,the record rate of medical records was 81.05%,the analysis rate of results was 33.07%,and the conformi-ty rate of bacterial culture examination records was 33.07%.Conclusion It is imperative to enhance the conformity rate of bac-terial culture examination records and improve the quality of medical records in terms of content.

关键词

细菌培养/记录/符合率/基线调查

Key words

Bacterial culture/Records/Coincidence rate/Baseline investigation

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出版年

2024
现代医院
广东省医院协会

现代医院

影响因子:1.332
ISSN:1671-332X
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