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目的分析探讨住院病案首页填写存在的缺陷问题,进一步提高病案首页书写质量。方法计算机检索万方、维普、中国知网数据库,收集2000年1月-2016年3月相关病案首页文献,绘制森林图,由异质性检验结果选择随机效应模型进行数据合并,对病案首页组成项目进行分组分析,进行敏感性和发表偏倚分析。结果此次Meta分析共纳入12篇文献,病案首页合并缺陷率为6.6%(95%CI:5.3%~7.9%),基本信息缺陷24%,诊断信息缺陷18.9%,手术信息缺陷9.4%。结论病案首页缺陷率较高,各项目填写缺陷问题不容忽视,首页缺陷内容中缺陷率较高表现为基本信息情况(姓名、地址、身份证号码、联系人错误)、诊断信息(诊断名称、主次顺序颠倒问题)以及手术信息(手术切口问题)的填写。病案管理专职人员和临床医师需进一步提高书写质量意识,确保病案首页的准确性和真实性,促进病案质量管理工作的完善。
Objective To analyze and discuss the existing defects in the first page of inpatient medical record and to further improve the quality of the first page of medical record. Methods We searched the database of Wanfang, Wipu and CNKI to collect the relevant literature from January 2000 to March 2016. We draw the forest map, select the random effects model from the results of heterogeneity test, Projects were grouped and analyzed for sensitivity and publication bias. Results A total of 12 articles were included in the Meta-analysis. The first case of combined medical record had 6.6% (95% CI: 5.3% -7.9%) of primary combined defects, 24% of basic information defects, 18.9% of diagnostic information defects and 9.4% of surgical information defects. Conclusion The first page of the medical records has a high defect rate. The defects of each item should not be overlooked. The high defect rate in the first page of the defect is the basic information (name, address, ID number, contact error), diagnostic information Reverse the order of the order) and surgical information (surgical incision problem) fill. Professional staff and clinicians need to further improve the writing quality awareness, to ensure the accuracy and authenticity of the front page of medical records, and to improve the quality of medical records management.