首页填写缺陷在病案中的发生情况分析和对策建议

Home page filling defects in medical records analysis and Countermeasures

目的:探讨首页填写缺陷在病案中的发生频次及对策。方法:收集病案资料信息1 221份,对其资料进行分析。结果:诊断信息缺陷频次明显高于其他3项(P<0.05),诊断填写不规范明显高于其他因素;手术、操作编码漏写发生频次明显高于其他项目(P<0.05)。结论:根据本次研究结果针对所发现的缺陷给予相应的解决对策,利于提高病案首页信息填写的准确性,对患者的治疗等具有积极的意义。

Objective:To investigate the frequency and countermeasures of filling out defects in medical records.Methods:Wecollected1221pieces of medical record information and analyzed the data.Results:The frequency of diagnostic information defectwas obviously higher than the other three items(P<0.05);diagnostic filling not standardized was significantly higher than otherfactors;and the frequency of operation,operation,coding and omission were obviously higher than those of other items(P<0.05).Conclusion:According to the results of this study,the corresponding countermeasures are given to improve the accuracy of the firstpage information of the medical record.It is of positive significance for the treatment of the patients.