病案首页信息填写存在问题分析

Analysis of the Influence of Information Writing in the Front Sheet of Medical Records on Medical Quality Management

病案首页信息不仅是医院开展医疗统计工作的基础,也是医院进行科学管理的客观依据。病案首页信息填写常见错误有主要诊断、确诊日期、诊断符合情况、抢救次数和成功次数填写错误。这些病案首页信息填写错误将会对疾病分类统计分析、病种管理、三日确诊率、危重病人抢救成功率等造成不同的影响。病案首页信息与医疗质量管理密不可分,建议:(1)将国际疾病分类列入医学生的基础教育教材;(2)将病案首页填写作为新进人员、进修生岗前培训的必备内容,并纳入等级医院评审标准;(3)在医疗质量管理过程中不断改进、提高病案首页的填写质量;(4)加强编码员培训学习、考核持证上岗,(5)将病案首页填写说明中有关"临床与病理符合"的内容重新定义。

The information in the front sheet of medical records is not only the foundation of developing medical statistics, but also an objective basis of hospital scientific management. Common errors of information writing in the front sheet of medical records includes： （1）mistakes in choosing ＂Principal Diagnosis＂ ; （2） error filling in ＂Date when diagnosis con firmed＂ （ 3 ） error filling in ＂Diagnosis coincidence＂ ; （ 4 ） error filling in ＂Rescue Numbers＂ and ＂Successful Rescue Numbers＂. The errors of information writing in the front sheet of medical records will exert different influence to statistical analysis of disease classification, disease types management, 3 - day - correct - diagnosis rate, successful rescue rate of acute and severe - filed patients. There＇s a close relationship between information writing in the front sheet of medical records and medical quality management. Suggestions： （1） to include ＂international classification of diseases＂ in teaching material of basic education for medical students （2） to place information writing in the front sheet of medical records as essential contents for pre - post training of new staffs and advanced students, and include it in evaluation criteria of hospital grades （3） to improve and enhance the writing quality of front sheet of medical records in the process of medical quality management （4） to intensify the coder training and coder work must hold relevant certificates 0 to redefine the contents of ＂coincidence between the clinical and the pathology diagnosis＂ in the filling instructions of front sheet of medical records.