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目的探讨临床管理路径对提高医院病案管理质量及患者对病案管理满意度的影响。方法将2015年4月至2015年10月我院病案科未实施临床管理路径前的病案管理质量与2015年11月至2016年5月实施临床管理路径后的管理质量进行比较。结果实施临床管理路径后病案管理质量优良率(96.53%)显著高于实施前(80.35%),病案资料排序错误、检查单缺失、封面资料填写错误、手术编码错误、上架顺序错误等常见错误总发生率(2.08%)显著低于实施前(10.90%),患者对病案管理的满意度(97.06%)显著高于实施前(80.88%),差异均有统计学意义(P<0.05)。结论实施临床管理路径可有效提高病案管理质量,减少病案资料错误发生,提高患者对病案管理的满意度。
Objective To explore the influence of clinical management path on improving the quality of hospital medical record management and patients’ satisfaction with medical record management. Methods The quality of medical records before the clinical management of pathology in our hospital from April 2015 to October 2015 was compared with the quality of management after the implementation of clinical management from November 2015 to May 2016. Results The excellent rate of medical records management (96.53%) was significantly higher than that before implementation (80.35%), the errors of medical record ordering, the absence of checklist, the error of cover materials, the wrong encoding of operation, the wrong order of shelves (2.08%) was significantly lower than that before implementation (10.90%). The patient satisfaction with medical records management (97.06%) was significantly higher than that before implementation (80.88%). The difference was statistically significant (P <0.05). Conclusion The implementation of clinical management path can effectively improve the quality of medical record management, reduce the occurrence of medical record data errors and improve patient satisfaction with medical record management.