5844份中医病案首页填写质量调查

A Quality Investigation on the Front Sheet of TCM Medical Record

目的分析中医病案首页填写缺陷,提出改进措施,以进一步提高中医病案首页的填写质量。方法将中医病案首页各项内容输入设计好的Excel表格中,对存在缺陷进行分类汇总、统计。结果 2014年1月—2014年6月共有出院病案5844份,有1876份病案首页存在不同程度的缺陷,缺陷率为32.10%;基本信息缺陷以现住址项目为主,医疗信息项目缺陷以医疗机构中药制剂项目为主。结论要提高中医病案首页填写质量,必须从源头抓起,采取多种方法对临床医师进行病案首页填写培训,为编码员提供更多学习机会,加强编码员在病案首页填写审核作用。

Objective To analyze defects of the front sheet of TCM medical records, put forward the improvement measures, and further improves the quality of fill out. Methods Input all contents of the front sheet of TCM medical record to Excel spreadsheet, and then aggregate and classify the defects. Results There are 5844 medical records from January 2014 to June 2014. There are about 1876 different degrees of defects, the defect rate is 32.10%; Basic information defects are current address, medical information project defects are medical organizations traditional Chinese medicine. Conclusion To improve the quality of home page to fill out, we must grab from fountainhead,adopt various training methods for clinicians, provide more learning opportunities for coders, and strengthen the audit function of coder in the medical record front page fill in.