针对病案首页质量问题的分析与对策

The Analysis and Countermeasure of Quality Problems about Medical Records Front sheet

目的通过对我院2010年病案首页缺陷情况进行分析并提出对策,为医院的病案质量管理和医疗安全提供参考。方法根据卫生部《病历书写基本规范》,对24,136份出院病案进行质量监控。结果病案首页缺陷主要以诊断信息和手术信息漏填、错填的比例最高。结论提高病案质量的关键是病案首页的质量,而对病案首页质量的把关,则需要医务人员努力提高专业技能和责任感。

Objectives This article analyzes and puts forward countermeasures about defect situation of medical record front sheet in our hospital in 2010,providing references for quality management of medical record and medical safety for the hospital.Methods According to Basic Norms of Medical Records Writing of ministry of health,it has quality monitor on 24136 hospitalization medical records.Results The proportion of missing filling and error filling of diagnosis information and surgery information is highest in defect of medical records front sheet.Conclusions The key to improve quality of medical records is the quality of medical records front sheet,while guarantee the quality of medical records front sheet needs medical personnel to take effort for improving professional skill and responsibility.