4397份新版病案首页入院病情归类分析

Classification Analysis of Admission Illness State of 4397 Cases of New Edition Medical Records Home Pages

目的分析2012新版病案首页入院病情填写情况,为进一步提高病案首页书写质量提供参考材料。方法对4397份住院病案首页中入院病情进行检查及统计分析。结果 4397份病历首页入院病情为1的(有临床明确诊断)4049例,占92%;入院病情为2的(临床尚未明确诊断)268例,占6.1%;入院病情为3的(情况不明)49例,占1.1%;入院病情为4的(无)31例,占0.7%。其中入院病情归类为4的诊断失误率最高,占41.9%。结论在应用2012新版病历首页的过程中,绝大多数临床医生对入院病情的前三项填写准确率较高,而对入院病情4的选择失误率较高,主要原因在于问诊遗漏。提示临床医生在询问相关病情时应细致全面,以提高病历书写质量。

Objective To investigate the admission illness state fill in situation of 2012 new edition medical records home pages and provide reference materials for improving the writing quality the home pages. Methods To conduct related examination and statis- tical analysis on the admission illness state of 4397 cases medical records home pages. Results Among the 4973 cases, there are 4049 cases have an explicit diagnosis, which take a proportion of 92%. 268 cases have no explicit diagnosis, which take a proportion of 6. 1%. 49 cases of home pages with unknown condition, which take a proportion of 1.1%. 31 cases hwk of diagnosis, which take a proportion of 0.7%. And also the last situation have the highest error rate of diagnosis, which take a proportion of 41.9%. Conclu- sion Most doctors can manage an accurate fill in of admission illness state when applying the 2012 new edition medical records home pages, but have a high rate of error diagnosis of cases lack of diagnosis, the reason may be omission in the interrogation. This prompts our doctors to be comprehensive and careful in the interrogation of related diseases, thus to improve the writing quality of medical records.