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目的规范病案首页的填写,提高病案首页主要诊断与手术操作填写质量。方法提取2012年2万份病案,其中疾病诊断与手术操作各1万份,了解主要诊断与主要手术操作的填写情况。结果 1万份住院病案的首页中主要诊断填写的缺陷率为12.5%;主要手术操作填写的缺陷率为21.6%。主要问题是名称书写不规范:包括英文缩写、笼统的名称、分解书写、主要诊断与主要手术操作的选择错误等。结论加强对临床医师进行ICD-10知识的普及、健全监督检查制度、加强病案管理人员把关作用等措施是提高病案首页质量的有效方法。
Purpose To standardize the first page of the medical record and improve the main diagnosis and operation of the first medical record. Fill in the quality. Methods Twenty thousand cases were retrieved in 2012, of which 10,000 were diagnosed and surgically treated respectively. The main diagnoses and the main operation were completed. Results In the first page of 10,000 hospitalized cases, the defect rate of primary diagnosis was 12.5% and the defect rate of primary surgical procedure was 21.6%. The main problem is the non-standard name writing: including English abbreviations, general names, written decomposition, the main diagnosis and the main choice of surgical errors. Conclusion It is an effective way to improve clinicians’ quality of homepage by strengthening the popularization of ICD-10 knowledge, improving the supervision and inspection system and strengthening the check-in of medical record administrators.