谈老年病区病案首页中疾病诊断相关项缺陷管理

Disease Diagnosis Related Items Defects Management of The Front Sheet of Medical Record of Geriatric Ward

对2013年3月304份住院病案首页中的疾病诊断相关项进行检查,发现病案首页填写的主要缺陷以出院主要诊断选择错误、出院诊断和医院感染漏填为主。增强医师责任心、加强医师主要诊断选择原则及病历书写的培训、加强编码员与临床医师的沟通,充分利用三级查房制度及病历质量监控等措施,才能提高老年病区病案首页填写的质量。

We found that the main defects were discharge diagnosis mischoose and discharge diagnosis errors, not filling of discharge diagnosis and hospital infection after checking disease diagnosis related items of 304 cases of the front sheet of medical record in March 2013. We should strengthen the main diagnosis selection principles and medical record writing training, strengthen communication between coders and clinicians, make full use of the three-level ward round system and medical record quality control measures, etc to improve the quality of the front sheet of medical record of the elderly ward.