住院病案首页填写质量缺陷调查分析

Quality Defect Analysis of the Front Pages of Medical Records

目的了解某医院归档后住院病案首页填写质量,针对存在的缺陷提出整改措施。方法随机抽取2017年1月-6月出院病案共530份进行病案首页检查,统计分析填写存在的缺陷,并分析成因及提出对策。结果病案首页缺陷共计发生频次378次,其中患者基本信息缺陷57频次,缺陷率15.08%;医疗信息错误123频次,缺陷率32.54%;诊断信息缺陷198频次,缺陷率52.38%。结论规范医师的诊断书写,建立标准化疾病诊断字典库;加强业务培训力度,宣传病案的法律意义;加速信息化建设,构建完善的病历质控体系,有助于提升病案首页的填写质量。

Objectives To understand the quality of the first page of medical records of discharged patients in a hospital, and put forward corrective measures for the existing problems. Methods A total of 530 medical records of discharged patients from January to June 2017 were randomly selected for the front pages examination.The defects were statistically analyzed and filled in, and the causes and were analyzed and the countermeasures were proposed. Results There were a total of 378 times of defects on the front pages of medical record, including57 times of defects in patients’ basic information, with a defect rate of 15.08%. Errors in medical information were123 times, and the defect rate was 32.54%. Diagnostic information defect was 198 times, defect rate 52.38%.Conclusions The doctors’ diagnostic writing should be standardizedand and establishing standardized dictionary of disease diagnosis was needed. Strengthen professional training and publicize the legal significance of medical record. Accelerating the construction of informatization and building a perfect quality control system of medical records were helpful to improve the quality of filling in the front pages of medical records.