某三级公立医院病案首页问题分析与改进

Analysis and improvement of the first page of medical records in a tertiary public hospital

目的分析住院病案首页存在的质量缺陷,查找原因并制定相应的整改措施,以提高病案首页质量。方法对某三级公立医院2019年01月01日-2019年12月31期间出院病案29022份进行系统抽样,每科100份,共计3203份出院病案,对其进行回顾性检查,统计分析病案首页填写中存在的缺陷及成因。结果3203份病案中有859份存在1077次缺陷;最突出的缺陷是主要诊断误填239次(22.19%)、身份证号错误160次(14.86%)和手术及操作名称漏填误填118次(10.96%),其中以临床医师漏填误填居多。结论病案首页主要诊断误填问题较为突出。应加强病案编码及临床科室病案首页填写的规范培训,并纳入临床科室绩效考核;着重提升医院系统信息化程度,保证病案首页填写质量。

Objective To analyze the quality defects existing in the front page of inpatient medical records,find out the causes and formulate corresponding rectification measures,so as to improve the quality of the front page of medical records.Methods systematic sampling was conducted on 29022 medical records discharged from a tertiary public hospital from January 1,2019 to December 31,2019,100 in each department,a total of 3203 discharged medical records,then,conduct a retrospective examination,and the defects and causes in filling in the first page of medical records were statistically analyzed.Results Among 3203 medical records,859 had 1077 defects;The most prominent defects are 239 wrong diagnoses(22.19%),160 wrong ID number(14.86%),and 118 wrong operation and operation names(10.96%),most of which were missed and filled by clinicians.Conclusion The main diagnostic errors in the first page of medical records are more prominent.The standardized training of medic-al record coding and filling in the first page of medical records of clinical departments should be strengthened and included in the performance evaluation of clinical departments;Focus on improving the information level of the hospital system and ensure the filling quality of the first page of medical records.