611份错位病案原因分析及对策

Reason Analysis of 611 Cases of Dislocation Medical Records and Relevant Countermeasures

目的通过对工作中查获的错位病案的错位原因分析,在病案管理各环节不断整改,为降低病案在开放式固定病案架上的错误率提供参考。方法收集我院病案室2009年1月1日-2013年12月31日因需要提供病案时查找到或工作时无意中发现的错位病案611份,归纳整理有效数据进行统计分析。结果错位病案中因看错号码放错位置548份;再次住院归档时放错病案袋17份;两本病案装订或叠在一起归档19份;不连号的两个病案袋叠在一起上架27份。在病案归档各环节进行整改后,病案的错位率呈逐年下降趋势,2009年错位发生率0.49%,2010年为0.25%,2011年为0.21%,2012年为0.19%,2013年为0.10%,2009年有未找到的错位病案5份,2010年后基本没有发现找不到的错位病案。结论要达到病案管理零差错还需在工作中不断总结经验、整改,才能最大效率地发挥病案的作用。

Objectives Through conducting reason analysis on dislocation medical records found in the work and continuously rectification in each link of medical records management, thus to provide reference for reducing the error rate in medical records on open fixed shelves. Methods To collect 611 cases of dislocation medical records found in our work while need to provide the medical records or not in the medical records department of our hospital from January 1st 2009 to December 31st 2013, then collect valid data and make statistical analysis. Results There were 548 dislocation cases misplaced because of wrong numbers, 17 dislocation cases misplaced because of filling into the wrong case bags while rehospitalized, 19 dislocation cases misplaced because of the two adjacent cases stacked together, 27 dislocation cases misplaced because of the two not even adjacent cases stacked together. The dislocation rate of medical records was decreasing year by year after the rectification of each link in medical records archiving, and it was 0.49% in 2009, 0. 25% in 2010, 0. 21% in 2011, 0. 19% in 2012 and 0. 10% in 2013 respectively. There were still 5 dislocation cases not found in 2009, but no dislocation cases were found after 2010. Conclusions We should constantly sum up experience and make rectification in the work of medical records management, so as to realize zero error case and give play to the function of medical records to the maximum extent.