病案首页填写存在的问题及对策探讨

Problems and Countermeasures Discussion of First Page Filling of Medical Records

目的分析病案首页填写中存在的问题,并且根据问题原因提出整改措施。方法随机抽选我院2785例患者病案首页填写为观察对象,抽选时间段为2013年1月至2019年5月,根据抽选病案首页填写存在的问题统计,分析病案首页填写存在的主要问题及原因。结果①诊断信息栏中存在的问题主要包括六个方面,分别是主要诊断选择不准确、诊断名称不规范、诊断栏填写不规范、病理诊断栏问题、损伤和中毒外部原因栏问题和根本死亡原因栏填写问题。②基本信息栏出现的填写问题主要包括两个方面,分别是基本信息填写错误和医疗支付款方式未对应付费或者是对应关系掌握不准确。③手术栏填写问题主要包括五个方面的内容,分别是科室所做操作忽略不填写、(一助、二助、麻醉师没有填写)、手术名称填写不规范、切开愈合填写随意、医师填写粗疏。结论根据病案首页填写中存在的问题,采取有效措施防止问题出现,从而保证病案首页填写质量。

Objective Analyze existing problems in the first page filling of medical record and propose corrective measures based on causes.Methods We chose 2785 patients in our hospital to fill in the first page of medical record from January 2013 to May 2019 as observation objects.According to statistics of problems in the first page of medical record,collect main causes of problems in the first page of the medical record.Results①problems in diagnostic information column included six aspects mainly,namely,inaccurate selection of main diagnosis,irregular diagnosis names,irregular filling in diagnosis column,problems of pathological diagnosis column,problems of injuries and poisoning external cause column,and filling of fundamental death cause column.②filling problems of basic information volume includes two aspects mainly,namely,incorrect filling of basic information and medical payment method not corresponding to payment or not accurate corresponding relationship.③filling problems in operation column includes five aspects mainly,namely,department operation being ignored,(not filling in the first,second assistant,anesthesiologist),not standardized operation name,random filling of incision healing,rough filling of physicians.Conclusion According to existing problems in the first page filling of medical record,it is necessary to take effective measures to prevent problems to ensure quality of the first page of medical record.