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目的通过检查病案首页缺陷,分析缺陷存在的原因,寻找提高病案首页质量的具体措施。方法抽检某院2016年1月-2016年6月出院病案20 947份,检查病案首页,按照基本信息、诊断信息、手术信息、住院费用进行分组统计并进行原因分析。结果抽查20 947份病历中,存在缺陷1320份,缺陷率为6.3%;其中诊断信息缺陷(包括入院初步诊断、出院诊断、病理诊断)284份,缺陷率为21.52%;手术操作缺陷245份,缺陷率18.56%;确诊日期缺陷241份,缺陷率18.26%;住院情况缺陷152份,缺陷率11.52%;住院费用缺陷85份,缺陷率6.44%;出院情况缺陷57份,缺陷率4.32%。结论病案首页存在缺陷的原因主要有病案首页网络自动化检测不完善、医师思想认识不到位、医院病案书写培训不得力等,医院在进一步加强医疗质量重要性教育,加强病案首页的质量控制与管理,加强病案首页书写培训的同时,采用网络自动化检测系统可极大促进病案首页正确率的提高,进一步促进诊疗数据精准率。
Objective To find out the specific measures to improve the quality of the first page of the medical records by examining the first page of the medical records and analyzing the causes of the defects. Methods A total of 20 947 medical records were collected from January 2016 to June 2016 in a hospital. The first page of the medical record was inspected. The basic information, diagnostic information, operation information and hospitalization expenses were grouped and analyzed. Results Among the 20 947 medical records, there were 1320 defects with a defect rate of 6.3%. Among them, there were 284 diagnostic information defects (including initial diagnosis, discharge diagnosis and pathological diagnosis) with a defect rate of 21.52%; 245 surgical defects, The defect rate was 18.56%. There were 241 confirmed date defects, the defect rate was 18.26%. 152 hospitalized defects were found, the defect rate was 11.52%. The hospitalization defect was 85, the defect rate was 6.44%. The discharge defects were 57 and the defect rate was 4.32%. Conclusion The main reasons for the existence of defects on the first page of the medical record are the first page of the medical record network automation testing is not perfect, the doctor’s thinking is not in place, the hospital record writing training ineffective, the hospital to further strengthen the importance of medical quality education, strengthen medical records quality home page, At the same time to strengthen the writing and training on the first page of medical records, the adoption of network automated testing system can greatly improve the accuracy of the first page of medical records and further promote the accuracy of medical data.