延边地区某医院病案填写错误情况分析

Analysis of filling in error condition of medical records in a hospital of Yanbian area

[目的]调查延边地区某医院病案信息,分析填写错误情况.[方法]收集延边地区某医院各科室2015年出院病案23 204份,对填写错误情况进行分析.[结果]眼科、口腔科、肾脏内科、血液内科和消化内科的病案出错率较高,分别为21.58%,20.76%,18.12%,15.81%和15.41%;感染科、老年病科、口腔科、肾脏内科和血液内科的病案首页出错率高于其他科室,分别为2.09%,2.01%,1.99%,1.89%和1.86%.[结论]延边地区某医院各科室病案填写错误情况较普遍.

OBJECTIVETo investigate the information of medical record,and to analyze their filling in error condition of medical records in a hospital of Yanbian area.METHODS A total of 23 204 cases of information of discharged medical records in internal medicine in 2015 were collected by the different departments and their filling in error condition of medical records in a hospital of Yanbian area was analyzed.RESULTSThe error rates of filling in error condition of discharged medical records were 21.58%in Dept of Ophthalmology,20.76% in Dept of Stomatology,18.12% in Dept of Nephrology,15.81% in Dept of Hematology and 15.41%in Dept of Gastroenterology,and the error rates,filling in error condition at homepage of discharged medical records were higher in Dept of Infecious Disease,Geriatrics,Stomatology,Nephrology and Hematology than in other departments in internal medicine,were 2.09% in Dept of Infectious Disease,2.01%in Dept of Geriatrics,1.99%in Dept of Stomatology and 1.89%in Dept of Nephrology and 1.86%in Hematology,respectively.CONCLUSIONThe situation of the filling in error condition of medical records is ubiquitous.