8581份病案首页信息质量分析

Quality analysis of first page information in 8581 cases

目的:通过对病案首页错误信息的分析,提高首页信息质量。方法:①利用病案编目模块统计病案归档情况。②采用全军网络版数据核查软件与人工检查相结合的方法,对2005年3月至5月出院的病案首页信息进行核查。结果:①3个月的病案按期归档率分别是91%、92%和92%。②基本信息错误占1.42%、医疗信息错误占12.84%、编目信息错误占47.92%、费用信息错误占37.82%。结论:病案首页信息错误不容忽视;加强首页环节及终末质量管理;提高医护人员质量意识及素质;完善和提高软件功能。

Objective： To raise the information quality through analyzing the mistakes on the first page of medical records,. Methods ： With the record catalogue module, statistics was made on the filing of records. From March to May in 2005, the information on the first page of the discharged was checked with a data check software and by manual inspection. Results： The rates of record filing in the 3 months were respectively 91%, 92%, 92%. The information mistakes amounted 1.42% for basic, 12.84% for medical, 47.92% for catalogue and 37.82% for cost, respectively. Conclusion ： The information mistakes in the first page of medical records should not he ignored. To improve the quality, the awareness of the staff, the function of softwares, and the management of end quality should he stressed.