病案首页完整性评价

Evaluation on Integrity of Home Page of Medical Records

目的通过分析病案首页填报完整性,为提高病案首页填报质量提供建议。方法提取2015—2016年某院住院病案首页数据,计算各项目填写完整度,总结出首页填报中存在的问题。结果 2015年和2016年首页项目填写完整率未达100.00%均有30余项。结论需加强监管,促进部门间的协作以提高病案首页填写质量。

Objective To analyze the integrity of home page of medical records thus providing suggestions for improving the filling quality of home page of medical records. Methods The data of hospitalization medical records home pages from 2015 to 2016 were selected, and the filling integrity of various projects were calculated, and the existing issues in the filling of home page were summarized. Results There were 30 items whose filling integrity rate did not reach 100.00% of home page from 2015 to 2016. Conclusion We need to enhance the supervision and promote the cooperation among departments to improve the filling quality of medical records home page.