人类辅助生殖技术病历书写质量分析
Quality Analysis of Medical Record Writing in Human Assisted Reproductive Technology
姚小成 1李艳梅 1莫似恩 1张秋珍1
作者信息
- 1. 广西壮族自治区生殖医院,广西壮族自治区,南宁市,530029
- 折叠
摘要
目的 通过对广西壮族自治区某院人类辅助生殖技术病历书写现状进行分析,找出病历书写存在的问题,探讨提高病历书写质量的对策及方法.方法 采用整群抽样法,抽取某院生殖中心病案信息系统2022年1月1日-2022年12月31日人类辅助生殖技术病历共5370份,由科室质控小组按照病案质控要求对其进行质量检查,将缺陷分类、缺陷次数等情况进行统计分析.结果 5370份病案中缺陷病案共1236份,总缺陷率23.02％,缺陷次数1835次.将缺陷情况按项目分为9大类,缺陷率由高到低依次为患者夫妇双方病史48.34％、知情告知同意书15.37％、控制性超促排卵监测表10.30％、采卵手术相关记录10.19％、ART门诊病案首页7.14％、其他项目4.96％、胚胎实验室相关记录1.74％、移植手术相关记录1.36％、病程记录/病例讨论0.60％.结论 缺陷率最高的为患者夫妇双方病史记录的欠缺,其次为知情告知同意书项目填写不全、控制性超促排卵监测表有漏填项目以及采卵手术相关记录不完善等问题.医院需要加强人类辅助生殖技术各项诊疗规范学习、健全病历质控管理体系等,促进病历书写质量提升,进而提高医院的医疗质量和医疗服务水平.
Abstract
Objectives To analyze the current situation of medical record writing of human assisted reproduction technology in a hospital in Guangxi Zhuang Autonomous Region,find out the existing problems of medical record writing,and explore the countermeasures and methods to improve the quality of medical record writing.Methods A total of 5370 medical records of human assisted reproductive technology were selected from the medical records information system of a reproductive center of a hospital from January 1st,2022 to December 31st,2022 by cluster sampling method.The quality control team of the department conducted quality inspection according to the requirements of medical records quality control,and carried out statistical analysis on the classification of defects and the number of defects.Results There were 1236 defect records in 5370 medical records,with a total defect rate of 23.02％and 1835 defects.The defects were divided into nine categories according to the items,and the defect rate was the medical history(48.34％),informed consent(15.37％),controlled super-ovulation monitoring table(10.30％),egg operation records(10.19％),front page of ART outpatient medical record(7.14％),other items(4.96％),embryo laboratory records(1.74％),transplant records(1.36％),and course record/case discussion(0.60％).Conclusions The highest defect rate was the lack of medical history records of the couple,followed by the incomplete filling of the informed consent form,the omission of the controlled super-ovulation monitoring form and the incomplete records of spawning surgery.The hospital needed to strengthen the study of the diagnosis and treatment norms of human assisted reproductive technology,improve the quality control and management system of medical records,promote the quality of medical records writing,and then improve the medical quality and medical service level of the hospital.
关键词
病历书写/人类辅助生殖技术/缺陷/质量/对策Key words
Medical record writing/Human assisted reproductive technology/Defects/Quality/Countermeasures引用本文复制引用
出版年
2024
NETL
NSTL
万方数据