2892份住院病案首页其他诊断漏填分析

Analysis on the Missing Disease Diagnosis in the Front Pages of 2892 Cases of Medical Records

目的分析住院病案首页其他诊断漏填的现状,并采取相应的措施降低出院诊断漏填率。方法随机抽取某院2015年5月-2015年10月的2892份终末病案,分析其他诊断漏填的科室分布,病种分布和诊断依据。结果抽查病案的其他诊断漏填率为13.14%,急诊科、神经外科和泌尿外科的其他诊断漏填率较高。常见的漏填病种有肾囊肿、肝囊肿和脂肪肝,漏填诊断的依据主要见于B超、化验和病程记录。结论外科住院病案首页其他诊断漏填率普遍高于内科。临床医师应注意B超和化验结果,以免漏填其他诊断。定期对医师进行培训与宣教是降低出院诊断漏填的有效措施。

Objectives To analyze the current situation of missing disease diagnosis in the front pages of the medical records, and take corresponding measures to reduce the rate of missing disease diagnosis. Methods From May 2015 to October 2015, 2892 terminal medical records were randomly selected to analyze the departments distribution, diseases distribution and diagnosis basis of missing diagnosis. Results The rate of randomly selected missing disease diagnosis was 13.14%, and the missing rates of emergency department, neurosurgery and urology of missing disease diagnosis were higher. Kidney cyst, liver cyst and fatty liver were usually missing in the front pages of medical records. The major basis of the diagnosis included b-ultrasonic, laboratory test and course records.Conclusions The rate of missing disease diagnosis on surgery department＇s medical records was higher than internal medicine departments.Clinical doctors should pay attention to the result of b-ultrasonic and laboratory, in order to avoid missing kidney cyst, liver cyst and fatty liver disease. Regular training and propaganda for doctors were effective measures to reduce the missing rate of disease diagnosis.