基于病案首页的某院手术分级管理现状分析

Analysis on the Present Situation of Operation Classification Management Based on the Front Pages of Medical Records

目的通过病案首页手术相关信息分析某院手术分级管理现状,为建立手术分级信息化管理系统提供依据。方法收集2016年1月1日-2016年6月30日5个外科科室手术病例第一术式,对病案首页手术级别、手术名称、术者资质及手术分级构成修正前后进行分析。结果手术级别、手术名称及术者资质缺陷率分别为36.74%、12.99%和1.74%;手术分级缺陷中以级别降低为主,占85.28%;三、四级手术占比由修正前50.42%提高到69.09%;各级手术中由高级别专业技术职务的医师完成手术占比相对较高,分别为48.82%、64.51%、84.76%、94.27%。结论医院应尽快建立手术分级信息化管理系统,实现手术名称与手术分级自动关联,提高手术分级数据的准确性;综合各级医师的专业特长、手术技术水平等情况限定医师手术权限并实行动态管理,避免高级别专业技术职务的医师垄断手术。

Objectives To analyze the present situation of operation classification management in a hospital through the relateci information of front pages of medical records, so as to provide the basis for establishing the operation classification information management system. Methods The first operation records of 5 surgical departments from January. 1st to June 30th in 2016 were collected. The operation grade, operation name, qualification and classification of operation before and after revision were analyzed. Results The operation grade, name, and qualification defect rates were 36.74%, 12.99% and 1.74%; in the lower level operation grading defects, accounting for 85.28%; three or four stage surgery accounted for by the correction before 50.42% to 69.09%; the doctor from high level professional and technical posts at all levels of operation accounted for the relatively high, were 48.82%, 64. 51%, 84. 76%, 94. 27%. Conclusions The hospital should establish operation grading management system as soon as possible, which could realize automatically link of the operation name and operation grade to improve the accuracy of operation grading data. It was suggested to limit the operation authority according to the actual situations of expertise and the operation technical level of the doctors at every level, implement the dynamic management, and avoid doctors with high level professional as well as technical positions monopolize surgery.