住院病案首页质量影响因素与对策

Impact Factors and Countermeasures of the First Page of Medical Records

目的通过住院病案首页填写缺陷分析,探讨病案首页数据质量影响因素与干预对策,提高住院病案首页数据质量。方法随机抽查2016年1月1日-2016年6月30日住院病案首页1579份,根据《住院病案首页项目填写说明》进行评价,针对病案首页问题进行质量和影响因素分析。结果 1579份病案首页填写缺陷前5位分别是个人信息缺陷23.12%;联系人信息缺陷18.30%;签名与质控缺陷13.68%;出院诊断缺陷13.30%;手术与操作缺陷10.47%。结论医院管理因素、信息系统因素、专业发展因素是导致病案首页填写缺陷的主要原因。做好病案首页质量管理,注重病案管理专业队伍建设,加强培训和多部门协作配合,依托信息化建设,不断改进和完善管理手段,保证病案信息的可信度及统计数据的有效利用。

Objective Based on the analysis of the defects in the first page of inpatient medical records, this paper discusses the factors affecting the quality of the first page data and the intervention measures, and improves the quality of the data. Methods Randomly selected 1579 copies of the first page of medical records in first half of 2016. According to the instructions of the first page of medical records, analyze the quality and influencing factors of the first page of medical records. Results The top 5 defects were the personal information defect （23.12%）, the contact information defect （18.30%）, the signature and quality control defect （13.68%）, and the discharge diagnosis defect （13.30%）; operation and operation defect （10. 47%）. Conclusion Hospital management factors, information system factors, professional development factors are the main reasons for the defects of the first page of medical records. We should do good to the medical record management, pay attention to team construction of medical record management, and strengthen the training and multi sectoral coordination and cooperation, relying on information construction, and constantly improve and perfect the management method, ensure the effective use of reliabilitv and statistical data of medical record information.