病案首页填写缺陷分析及对策建议

Defect Analysis and Countermeasure Suggestions of the Front Sheet of Medical Records

目的通过抽查2013年1月至2014年9月出院归档的病案首页1663份,进行质控统计、分析,找出缺陷原因,为医院病案信息质量管理与医疗安全提出改进措施。方法依据原卫生部《病历书写基本规范(2010版)》、军区卫生部病案质量检查标准及病案首页质量检查标准细则,抽查1663份出院病案首页质量进行质量检查。结果病案首页质控检查出基本信息缺陷837频次(17.02%)、诊断信息缺陷2111频次(42.92%)、手术信息缺陷394频次(8.01%)以及其它信息缺陷1577频次(32.05%)等四个部分共29项4919频次缺陷;并对内、外科系统各科病案首页缺陷分布进行了统计。结论病案首页质量缺陷令人堪忧,应采取各种方法加强医务人员培训、提高病案首页填写知识培训入手,修炼临床基本功、促进病案首页质量提升,确保医疗信息质量与医疗安全。

Objective To check 1663 copies of archived medical record from January 2013 to September 2014, perform quality control statistics, analysis, identify the causes of defects, suggest improvements for the hospital medi cal record information quality management and medical safety.Methods 1663 copies of the front sheet of medical record were checked according to former Health Ministry＆quot;basic norms of medical writing （2010 Edition）＆quot;,the headquarters record quality inspection standards and medical record quality inspection standard rules.Results the basics defect 837 frequency （17.02%）,diagnostics defect 2111 frequency （42.92%）, surgical Information defect 394 frequency （8.01%）, and other information defect 1577 frequency （32.05%）, etc. a total of 29 item 4919 frequency defects. inside and surgical medical record system subjects conducted a statistical distribution of defects. Conclusion medical record quality defects is worrying, various methods should be taken to strengthen the medical staff training. We should improve clinical practice basic skills, promote the quality of the medical record and ensure the quality of medical information and medical safety.