病案首页应用中存在的问题及措施

The Problems Existing in the Application of Home Pages of the Medical Records and Relevant Countermeasures

按照《卫生部关于修订住院病案首页的通知(卫医政发[2011]84号)》和上海市《关于本市医疗机构使用新版《住院病案首页》的通知(沪卫医政[2012]78号)》的要求,自2013年1月1日起,本院开始使用新版病案首页。就上半年使用过程中,我们对部分病历随机抽样调查,发现病案首页上疾病诊断填写不完整的有18.88%,诊断编码和手术编码空缺的有57.34%,首页其他信息缺失或错误的占14%。病案首页上的内容填写不完整,甚止有误,成了现阶段工作中存在的主要问题。就此,我们提出了提高病案首页书写质量、建立信息共享平台和完善信息导入等措施,来提高病案管理的质量和效率。

According to the requirements of ＂Notice about the revision of home pages of medical records issued by The Ministry of Health＂ and ＂Notice of the application of new edition of medical record home pages in the medical institutions in Shanghai＂, our hospital started to apply the new edition of medical record home pages since Jan 1st, 2013. During the first half of the year of application, we conducted random sample on some of the medical records and found disease diagnosis of 18.88% of the home pages were incomplete, 57.34% were lack of diagnosis coding and operation coding and 14% of the home pages have others mistakes or information loss. There were some missing and even wrong information in the home pages of medical records, which was the main problem of the current work. Therefore,we put forward countermeasures such as improving the quality of medical records writing, establishing the platform of sharing information and perfecting the information import to improve the quality and efficiency of the medical record management.