住院患者基本信息缺陷分析及干预

Defects Analysis on the Basic Information of Hospitalized Patients and Intervention Measures

目的分析某医院住院患者基本信息缺陷情况,提出干预措施。方法回顾性核查某院2016年1月-2016年6月住院患者基本信息,将缺陷信息按缺陷类型及科室分布情况等进行归类总结、统计和分析。结果 2016年1月-2016年6月住院患者基本信息47 879份,存在缺陷的8716份,缺陷率18.19%,其中缺陷发生率最高的是外科系统,缺陷率26.34%;妇产科系统缺陷发生率最低,为12.97%。结论规范住院患者基本信息采集登记流程及严格管理制度,强化责任意识和质量意识,加强环节质控,完善提升信息系统辅助功能,是提高患者基本信息完整性、准确性的有效干预措施。

Objectives To analyze the defects situations of the basic information of the hospitalized patients in a hospital,and put forward the intervention measures.Methods The basic information of inpatients in a hospital from January to June 2016 was retrospectively reviewed.To conduct classification and summary according to the types of defects and the distribution of the departments,and also the statistics and analysis were carried out.Results There were 47879 copies of basic information of hospitalized patients from January to June in 2016,8716 copies of them existing defect,the defect rate was 18.19%.In which the highest incidence of defects was surgical system,the defect rate was 26.34%,the lowest incidence of defects was department of obstetrics and gynecology,the defect rate was 12.97%.Conclusions The effective intervention measures to improve the integrity and accuracy of the basic information of patients included standardizing the basic information registration process of the inpatient,strengthen the sense of responsibility and sense of quality,enhance the link quality control and improve the information system of auxiliary function.