中医电子病案首页质量缺陷分析与对策

Quality Defect Analysis and Countermeasures about the Front Sheet of Electronic Medical Records of Traditional Chinese Medicine

目的为了促进中医电子病案首页质量的提高,对某院中医电子病案首页填写质量存在问题进行分析。方法对2010年出院中医病案18,320份进行书写质量检查,分析存在问题根源。结果发现出院的中医电子病案首页18,320份,其中存在使用西医诊断、中医治疗类别填写错误问题的有1726份,占出院中医电子病案的9.42%。结论问题存在根源主要是对中医病案首页资料的重要性认识不足,对病历书写基本规范不了解,相关业务知识匮乏。针对问题,采取强化中医诊断相关业务培训,反复强调病案首页填写的重要性,改进制约措施后,中医病案首页填写质量有明显提高,缺陷病案首页由原来的9.42%降低到4.6%。

Objective To analyze defects of the front sheet of electronic medical records of Traditional Chinese Medicine and promote the improvement of quality.Methods Inspecting writing quality of 18320 medical records of TCM,analyzing the root of the problem.Results There were 1726 medical records have problems about using western medicine diagnosis and error treatment category of TCM,accounting for 9.42%.Conclusion Problems root is doctors don＇t realize the importance of the front sheet of electronic medical records of TCM,don＇t understand writing basic norms,and lack of related knowledge.The writing quality had increased significantly after strengthening relevant business training of TCM diagnosis and emphasizing the importance of the front sheet writing.The defect rates drop from 9.42% to 4.6%.