病案首页疾病诊断缺陷分析

Defects Analysis on the Diseases Diagnosis in the Home Pages of Medical Records

目的调查病案首页疾病诊断存在缺陷,以提高疾病诊断规范性,保障疾病诊断相关分组(DRGs)系统顺利实施。方法专业病案人员对某三甲医院2012年8月2日至8月8日所有出院病案进行调研分析,根据北京市卫生局京卫医字[2007]17号《关于规范住院病案首页填报工作的通知》的相关要求,找出临床疾病诊断书写中的缺陷。结果共调研916份出院病案,存在书写缺陷主要为主要诊断错误,诊断名称不规范,漏诊及手术及操作错误。其错误的原因:其一是DRGs对于诊断书写有自己的规定和特点,医生还没有深入了解,造成主要诊断选择等问题存在;其二是医师填写不认真,没有统一的书写规范。结论应该采取规范临床诊断和加强DRGs的宣讲等措施,可以使DRGs更客观对医院管理和医疗质量进行评价。

Objective To inspect the defects existing in the diseases diagnosis in the home pages of medical records,so as to improve the normativity of diseases diagnosis and guarantee the smoothly implementation of diseases related grouping system （DRGs）.Methods To conduct a inspection analysis on the medical record of all the patients discharged from August 2nd to 8th by professional medical records staff of a three A tertiary hospital,then found out the defects in the writings of clinical disease diagnosis according to the related requirements of ＂Notification on Standard writing in Home Pages of Hospitalization Medical Records＂ in [2007] 17 documents announced by the Beijing Municipal Health Bureau.Results A total of 916 cases of medical records were reviewed,the mainly writing defects were respectively mistakes of main diagnosis,lack of standardization in diagnosis names,missed diagnosis and errors of operation terms.And the reasons were DRGs had its own regulations and characters in the writing of diagnosis while doctors lack of understanding,then caused problems existing such as the selection of principal diagnosis.The other reason was the doctors＇ careless writing and lack of unique writing norms.Conclusions We should take measures such as standard clinical diagnosis and strengthening the propaganda of DRGs,so as to enable DRGs evaluate the hospital management and medical treatment quality more objectively.