中医皮肤科病案首页质量分析与对策

Analysis of the Quality and Countermeasure of Inpatient Medical Record of Chinese Medicine

目的对某中医医院皮肤科终末病案首页质量缺陷进行分析并提出解决方案,提高病案质量。方法对2016—2017年40份中医皮肤科归档病案问题首页进行终末质量检查,分析首页错误,并对首页典型问题情况进行分类统计分析。结果 40份中医皮肤科首页缺陷病历中,诊断不准确病案17份,诊断不完整病案11份,编码错误病案6份,操作填写不完整病案2份,QY组(主要诊断与主要手术及操作无关)问题病案2份,病案打印问题2份。结论加强病案书写培训,加强学习专科疾病,熟悉疾病诊断及操作编码,对其他科室疾病编码做到熟悉了解。严格审查病案,做到病案完整性、准确性,不漏诊、不误诊。强化全科医师的学习工作,建立合理的考评机制。

Objective To analyze the quality defect of the first page of the dermatology terminal of a traditional Chinese medicine hospital and propose a solution to improve the quality of the case.Methods A final quality inspection is conducted on the first page of the 40 TCM dermatological archives of dermatology from 2016 to 2017.Analyzing the first page error.The typical problems of the homepage are classified and analyzed.Results In 40 cases of dermatology home defects,17 cases were diagnosed incorrectly,11 cases of incomplete diagnosis,6 cases of coding errors,2 cases of incomplete medical record,QY group has 2 cases and 2 cases of the copying problem.Conclusion Strengthen the training of medical records writing,strengthen the study of specialized diseases,be familiar with disease diagnosis and operation coding,and be familiar with the coding of other department diseases.Strict review of the case,the integrity of the case,accuracy,not missed,not misdiagnosed.To strengthen the study of general practitioners and establish a reasonable evaluation mechanism.