目的：研究聚类分析方法在医院病案质量综合评价与分析中的运用。方法：对北京市某医院2013年全年4238份环节病案进行电子病案质控，并对其中4011项病案缺陷进行分类，将病案缺陷分类数据进行聚类分析。结果：将内科组与外科组临床科室按照病案缺陷类型的相似性及病案缺陷数量进行归类，参考每类科室的总病案缺陷率，综合评价出北京某医院各临床科室病案质量的优劣及各科室常见缺陷类型。结论：聚类分析方法不但能够综合评价临床科室病案质量，而且可以按照病案缺陷的相似度对科室进行分类，帮助科室找出常见病案缺陷类型，有效地进行病案质量持续改进，该方法还可以拓展应用于医院管理的多个领域。%Objective: To study the application of cluster analysis in comprehensive evaluate and analysis of medical records'quality.Meth-ods:4238 medical records have been checked by EMR system in 2013, and their 4011 medical records'defects were classified by cluster analy-sis.Results: According to the similarity of medical records'defects and the number of medical record's defects to cluster classify three classifica-tion in both internal medicine group and surgical group clinical departments, and refer to general medical record defects'rate per class to compre-hensive evaluate the clinical departments'medical records'quality and the common defects'type, to help the medical department provide personal-ize training to different doctors.Furthermore, compared with cluster analysis method and traditional method, the former is more precise and scien-tific and can provide more accurate information for hospital management to make decision.Conclusion:Cluster analysis not only can comprehen-sive evaluate the quality of medical records, but also can be used to classify the departments by the similarity of the medical records'defects and help the clinical departments identify their commonly made mistake in medical records'writing at the same time.Furthermore, this method can make the continuous quality improvement of medical records faster and better, and it also can be applied in many other fields of hospital management.
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