住院病案首页填写问题分析及改进

Analysis on Defects in the Filling of the Front Pages of Hospital Medical Records and Improvement Measures

目的检查分析住院病案首页填写问题,并针对问题提出改进措施。方法依据国家相关住院病案首页填写规范,对某院2019年1月1日-2019年6月30日期间出院的全部39802份住院病案首页进行质量监控,分析病案首页填写问题。结果总体缺陷填报率为19.74%。病案首页填写中出现的主要问题是其他诊断漏填,缺陷率为5.82%;漏填发生率最高的是贫血和低蛋白血症;患者身份证号、出生日期不符合或漏填,缺陷率为4.02%;其他手术编码漏填、错填,缺陷率为3.58%;主要手术编码错填,缺陷率为2.49%;主要诊断填写错误,缺陷率为1.96%;患者单位地址漏填,缺陷率为1.86%。结论住院病案首页填写中其他诊断的漏填现象严重,应注意检验报告中发现的疾病和持续时间短的疾病,同时还应加强登记管理,严格执行三级质控制度,强化医师培训和责任心的培养,提高病案首页填写质量,为DRGs实施打下坚实基础。

Objectives To control the quality of the front page of hospital medical records and analyze the defects,and propose improvement measures for the problem.Methods 100%quality control was conducted on the homepage of 39,802 inpatient cases between January 2019 and June 2019 in our hospital.To analyze the defects in the filling of the front pages and propose improvement measures.Results According to statistical analysis,the overall defect filling rate was 19.74%.The main problems in the filling of the front page of the medical record were other diagnosed missing filling which the defect rate was 5.82%,among them,the incidence of anemia and hypoproteinemia were the highest.Defect rate of patient ID number,birth date not matching or miss filled was 4.02%.Defect rate of other surgical codes missing and incorrectly filled,was 3.58%.Defect rate of the main surgical codefilledincorrectly was 2.49%.Defect rate of the main diagnosis filled incorrectly was 1.96%.Defect rate of the patient unit address missing was 1.86%.In response to the above problems,a series of improvement measures had been taken,such as strengthening basic information registration management,regular training of physicians,training and evaluation of coders,and improvement of information systems.Conclusions The basic information,diagnosis code,and surgical code in the front page of the medical record were easily missed or incorrectly filled.Among them,other diagnosed leaks were serious,and attention should be paid to the diseases found in the test report and diseases with short duration.Registration management should be strengthened,three levels of quality control should be strictly implemented,doctor training and responsibility should be strengthened,and the quality of the medical record front pages should be improved to lay a solid foundation for DRGs implementation.