5000份住院病案首页质量缺陷分析

Quality Defect Analysis of the Home Pages of 5000 Cases of Hospitalized Medical Record

目的分析住院病案首页书写中存在的缺陷,探索建立完整的住院病案首页质量控制体系,提高住院病案首页书写质量。方法抽查归档病案,按照《住院病案首页部分项目填写说明》(卫医政发〔2011〕84号),对某院2014年9月-2014年10月的5000份住院病案首页进行检查,并对存在的缺陷进行统计分析。结果 5000份住院病案首页的缺陷率为39.1%,错误病案项目数量为2629项,患者基本信息缺陷率为45.6%;临床诊疗信息缺陷率为38.2%;其它信息缺陷率为16.2%等。结论提高住院病案首页质量,必须加强临床医师培训,借助医院信息化技术建立住院病案首页事前、事中、事后的全方位日常控制体系。

Objectives To analyze the defects existing in the writing of the home pages of inpatient medical records, explore the establishment of a complete quality control system, and improve the writing quality of the homes pages of inpatient medical records. Methods To check 5000 home pages of discharged and archived medical records from September to October of 2014 according to the requirements of the＂Filling in Instructions of Partial Items of New Edition of Medical Records＂by the Health Planning Commission in 2011, and made statistical analysis of defective records. Results The defect rate of the home pages of 5000 medical records was 39.1%, there were 2629 incorrect items, defect rate of patients basic information was 45.6%, the defect rate of clinical diagnosis and treatment information was 38.2% and the other information defect rate was 16.2%, etc. Conclusions To improve the quality of home pages of inpatient medical record, we should start from the source, strengthen clinical training, take advantage of hospital information technology, and establish a comprehensive daily control system in advance, in the matter and after the event of home pages of inpatient medical records.