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目的研究某院肾内科电子病历首页填写过程中的常见问题,总结防范措施,提高病案首页质量;方法随机选取2016年1月-2016年12月某院肾内科终末病案2000例,根据原卫生部下发的《病历书写基本规范》国家卫计委《住院病历质量考核评分标准》,评价其首页填写过程中的常见问题,进行统计分析。结果某院肾内科电子病历首页常见缺陷包括:基本信息填写不完整、不规范220例,占11.00%;主要诊断选择错误28例,占1.40%;诊断书写不规范166例,占8.30%;病理诊断及院内感染填写不完整或漏填26例,占1.30%;手术操作名称不规范62例,占3.10%;切口愈合等级填写不规范或漏填32例,占1.60%;离院方式选择错误86例,占4.30%。结论病案首页填写存在许多问题,通过加强病案首页书写的规范性、准确性和可靠性管理,可提高病案首页书写质量,全面提升医疗管理水平。
Objective To study the common problems in the process of filling the first page of electronic medical record of nephrology in a hospital and summarize the precautionary measures to improve the quality of the first page of medical records. Methods From January 2016 to December 2016, Ministry issued the “basic norms of medical records” National Health Planning Commission “in-hospital medical records quality assessment standards” to evaluate the home page fill in the common problems and make statistical analysis. Results The common defects in the first page of electronic medical records of a hospital were as follows: the basic information was not complete and was not standardized in 220 cases, accounting for 11.00%; the main diagnostic choices were incorrect in 28 cases (1.40%); the diagnosis was not standardized in 166 cases (8.30%); Diagnosis and nosocomial infection in incomplete fill or fill in 26 cases, accounting for 1.30%; 62 cases of non-standard operation name, accounting for 3.10%; incision healed grade filled or irregular fill 32 cases, accounting for 1.60%; leaving the wrong way to choose 86 cases, accounting for 4.30%. Conclusion There are many problems in the first page of medical record. By strengthening the standardization, accuracy and reliability management of the first page of medical record, the writing quality of the first page of medical record can be improved and the overall medical management level can be improved.