杜爽+孟开

[摘要] 目的 建立一套适合北京市实际情况的公立医院运行病历质量评价指针体系。 方法 应用文献资料法、个人深入访谈法收集北京市公立医院运行病历质量评价指针体系的初条目池；采用德尔菲法构建运行病历评价指标体系并确定指标的权重。 结果 构建出适用于北京市公立医院运行病历质量评价的指针体系，该体系包括一级指标5个，二级指标23个，三级指标87个。 结论 参与本次研究的专家权威程度高，协调性较好，构建的北京市公立医院运行病历评价指标体系具有较好的信度和效度。

[关键词] 运行病历；评价指标体系；德尔菲法；病历品质

[中图分类号] R197.3 [文献标识码] A [文章编号] 1673-7210（2017）11（a）-0152-05

Study on quality evaluation index system of running medical records for public hospitals in Beijing

DU Shuang1，2 MENG Kai1▲

1.Department of Social Medicine and Health Administration， School of Health Administration and Education， Capital Medical University， Beijing 100069， China；2.Medical Record Room， China-Japan Friendship Hospital， Beijing 100029， China

[Abstract] Objective To establish a quality evaluation index system of running medical records for public hospitals in Beijing. Methods Items of running medical records quality evaluation index were collected using literature analysis and in-depth interview. Quality evaluation index system of running medical records was established and weight of indicators were determined using Delphi method. Results Quality evaluation index system of running medical records for public hospitals in Beijing was established， including 5 grade Ⅰindicators， 23 grade Ⅱ indicators， and 87 grade Ⅲ indicators. Conclusion Experts participating in this study have high authority and good coordination， which makes quality evaluation index system of running medical records for public hospitals in Beijing has high reliability and validity.

[Key words] Running medical record； Evaluation index system； Delphi method； Medical record quality

運行病历即由医护人员书写患者在诊疗期间，但尚未完成归档的法律文书[1]。运行病历质量不仅是患者健康档案、医保的主要依据，也是处理医疗纠纷的重要证据，还能反映医院的学术水平、管理水平[2-3]。如今许多医院都开展运行病历检查活动，但由于采用和终末检查一样的方法，也使用终末病历检查标准，并没有针对运行病历检查特点制定检查方法和评价标准，所以检查效果并不理想[4]。为此，本研究根据原国家卫生部2010年颁布的《病历书写基本规范》，结合北京市公立医院当前医疗环境和医疗水平，制订适用北京市公立医院的运行病历质量评价指针体系。

1 材料与方法

1.1 通过文献检索与专题访谈构建条目池

查阅国内外有关运行病历质……