住院病案首页填写缺陷分析及改进措施

Defect Analysis and Improvement Measures of the Front Sheets of Medical Records

目的检查某院住院病案首页,发现数据填写存在的缺陷,找出相应的改进措施。方法选取某院九个临床科室为DRG试点科室,随机抽取2016年1月至6月出院的其中583份病案,采用描述性方法,分析住院病案首页填写存在的缺陷。结果 583份住院病案首页填写有缺陷的共327份,填写缺陷率56.1%,常见的缺陷有主要诊断选择错误、诊断名称不规范、漏诊断、手术及操作名称不规范、漏登记操作、入院病情选择错误及病案首页项目填写不全。结论目前该院住院病案首页填写质量仍有较大提升空间。

Objective To check the quality of the medical record in a hospital, analyze the defects, and find out the corresponding improvement measures. Methods Nine clinical departments were selected as DRG pilot departments, and 583 cases were randomly selected from January 2016 to June. The descriptive method was used to analyze the defects of the medical record homepage. Results There were some defects in 327 copies of medical record home page among 583 copies, the rate was 56. 1%, and nonstandard diagnosis, missed diagnosis and operation, wrong ju common defects were wrong primary diagnosis, dgment of admission condition, and empty items. Conclusion The quality of medical record home page in the hospital still has a large room for improvement.