住院患者基本信息录入常见错误分析

Analysis of the Common Mistakes in Information Entry of Inpatients

目的降低住院患者基本信息录入错误率。方法收集2012年1月至2013年12月,福州市某三级医院病案室在册登记的"住院患者基本信息修改记录本"、《住院患者基本信息修改申请表》和病历等资料,统计基本信息错误的类型,分析发生错误的原因。并在采取干预措施实施前后一年,观察住院患者基本信息修改率变化情况。结果跟踪数据采集过程的质量持续改进情况,信息修改率从2012年度的1.18%降低到2013年度的0.78%,干预收效明显。结论干预措施的执行,有效减少住院患者基本信息发生错误的概率。并结合医院实际,提出系列持续改进措施,收到成效。

Objective To reduce the occurrence of information entry mistakes of inpatients.Method The causes for wrong patient information were collected from ＂correcting medical records and applications of correcting wrong information of inpatients＂from January 2012 to December 2013.Then the effect was analyzed by comparing before and after taking related intervening measures.Results The occurrence of patient＇s wrong information reduced from 1.18% in 2012 to 0.78% in 2013.Conclusion The intervening of false data and strategies for correction patient information were of significance in reducing the frequency of changing personal data.