病案首页主要诊断填写缺陷分析及对策

The Analysis and Countermeasure of Defects of Chief Diagnosis of the Front Sheet of Medical Records

目的规范病案首页的填写,提高病案首页主要诊断填写质量。方法回顾性调查并分析2007年6月至2011年6月病案首页主要诊断填写情况。结果 13,920份住院病案的首页中主要诊断填写缺陷率为14.5%,主要问题是诊断名称书写不规范或缩写、诊断术语不规范、主要诊断资料不完整或选择错误、相关诊断分解书写等。结论加强对临床医师进行ICD-10知识的普及、健全监督检查制度、加强病案管理人员把关作用等措施是提高病案首页质量的有效办法。

Objective To standardize the filling of front sheet of medical records and improve the filling quality of principal diagnosis. Methods We retrospectively survey and analyze the principal diagnosis filling of the front sheet of medical records from June 2007 to June 2011. Results The filling defect rate of principal diagnosis was 14.5% in 13920 front sheets of medical records. The main problems were principal diagnosis or abbreviation and diagnosis terms are lack of standardization, incomplete principal diagnosis data or wrong choice, wrong merge, etc. Conclusion There were many effective ways to improve the quality of the medical record such as improving the understanding of the medical staff of the importance of medical record information, strengthening the ICD-10 popularity of clinicians, improving the supervision and inspection system and strengthening the role of the gatekeeper of medical record man- agement.