规范病案首页疾病填写对医院感染率的影响

Influence of standard filling out first page of medical record on prevalence rate of nosocomial infections

目的探讨规范病案首页疾病填写对医院感染率的影响,为医院感染控制工作提供临床指导。方法选取2012年3月-2016年2月医院收治的患者2748例,依据入院时间分为2组。规范组(2014年3月-2016年2月)1469例,不规范组(2012年3月-2014年2月)1279例;选取同期在医院上岗的医务人员416名,规范组(2014年3月-2016年2月)214名,不规范组(2012年3月-2014年2月)202名,比较两组医务人员的病案规范水平、病案首页疾病填写情况、患者医院感染发生率、投诉、纠纷和满意率。结果规范组214名医务人员的病案规范意识、病案规范相关知识、病案规范程度均明显优于不规范组,差异有统计学意义(P<0.05);规范组1469份病案,遗漏19例(1.29%),不准确22例(1.50%),错误12例(0.82%);不规范组1279例,遗漏102例(7.97%),不准确168例(13.14%),错误29例(2.27%)。规范组1469例,医院感染率为0.75%,不规范组1279例,医院感染率为5.94%。规范组的投诉、纠纷、满意率分别为0.34%、0.27%、97.00%;不规范组的投诉、纠纷、满意率分别为3.05%、5.94%、83.03%。结论规范病案首页疾病填写能够增强医务人员病案规范意识,减少病案填写遗漏、错误问题,降低患者医院感染发生率,值得临床推广。

OBJECTIVE To explore the influence of standard filling out the first page of medical record on prevalence rate of nosocomial infections so as to provide guidance for control of the nosocomial infections.METHODS A totalof 2748 patients who were treated in hospitals from Mar 2012 to Feb 2016 were enrolled in the study and divided into two groups according to the admission time,1469 patients who were admitted from Mar 2014 to Feb2016were assigned as the standard group,and 1279 patients who were admitted from Mar 2012 to Feb 2014 were set as the non-standard group;meanwhile,416 health care workers who were on duty were enrolled in the study,214 health care workers were assigned as the standard group（from Mar 2014 to Feb 2016）,and 202 health care workers were set as the non-standard group（from Mar 2013 to Feb 2014）.The level of standard medical record,status of filling out the first page of medical record,incidence of nosocomial infection in patients,and rates of complaint,dispute,and satisfaction were observed and compared between the two groups of health care workers.RESULTS There was significant difference in the awareness of standardization of medical record of the health care workers,related knowledge of standardization of medical record,and degree of standardization of medical record between the standard group and the non-standard group（P〈0.05）.Among the 1469 medical records in the standard group,19（1.29%）cases were missing,22（1.50%）were inaccurate,and 12（0.82%）cases were wrong.Among the 1279 medical records in the non-standard group,102（7.97%）were missing,168（13.14%）were inaccurate,and 29（2.27%）cases were wrong.The incidence of nosocomial infection was 0.75%among the1469 patients in the standard group,and the incidence of nosocomial infections was 5.94% among the 1279 patients in the non-standard group.The rates of complaint,dispute,and satisfaction of the standard group were 0.34%,0.27%,and 97.00%,respectively;the rates of complaint,dispute,and satisfaction of the non-standard group were 3.05%,5.94%,and 83.03%,respectively.CONCLUSIONThe standard filling out of the first page of medical record may intensify the awareness of standardization of medical record,reduce the problems of missing,wrong filling out the medical records,and prevent the nosocomial infections;it is worthy to be promoted in the hospital.