肾内科电子病历首页填写过程中常见问题与防范

Common Problems and Countermeasures in the Filling of Front Pages of Electronic Medical Records in Nephrology Medicine Department

目的研究某院肾内科电子病历首页填写过程中的常见问题,总结防范措施,提高病案首页质量;方法随机选取2016年1月-2016年12月某院肾内科终末病案2000例,根据原卫生部下发的《病历书写基本规范》国家卫计委《住院病历质量考核评分标准》,评价其首页填写过程中的常见问题,进行统计分析。结果某院肾内科电子病历首页常见缺陷包括:基本信息填写不完整、不规范220例,占11.00%;主要诊断选择错误28例,占1.40%;诊断书写不规范166例,占8.30%;病理诊断及院内感染填写不完整或漏填26例,占1.30%;手术操作名称不规范62例,占3.10%;切口愈合等级填写不规范或漏填32例,占1.60%;离院方式选择错误86例,占4.30%。结论病案首页填写存在许多问题,通过加强病案首页书写的规范性、准确性和可靠性管理,可提高病案首页书写质量,全面提升医疗管理水平。

Objectives To explore common problems of the front pages of medical records in the department of nephrology of our hospital, and summary countermeasures and improve the quality of the front pages of medical records. Methods 2000 cases of medical records from our hospital from January to December in 2016 were enrolled in this study, and checked contrast to the ministry of health medical record writing basic specifications and quality standard of inpatient medical records, and analyze and count all kinds of defects. Results The common defects of front pages of electronic medical record in our hospital including： the basic information was not complete and standardized（220 cases, 11.00%）, primary diagnostic selection error（28 cases, 1.40%） and diagnostic writing were not standardized（166 cases, 8.30%）, the pathological diagnosis and the hospital infection were not complete or not filled（26 cases, 1.30%）, operation name was not standardized or not filled（62 cases, 3.10%） and wound healing grade was not standardized or not filled（32 cases,1.60%）, leave hospital mode selection error（86 cases,4.30%）. Conclusions There were many problems existing in the filling of the front pages of medical records, we could improve the quality of medical records and the level of medical management comprehensively through strengthening the standardization, accuracy and reliability of the front pages of the medical record.