某三级医院住院病案首页信息填写缺陷分析

Analysis on the Defects of the First Page Information Filling of Inpatient Records in a Tertiary Hospital

目的:通过对住院病案首页信息缺陷分析,规范病案首页填写,提高病案首页数据质量。方法:根据某院2019年1月1日至11月30出院病历共计14736份,其中抽查病例共计10316份病例,设立专职质控医师根据《住院病案首页数据填写质量规范(暂行)》相关规定进行病案首页质量检查和登记。结果:10316份病例中缺陷项目共计4573例次,其中基本信息缺陷为1205例次,占比11.7%,诊疗信息缺陷2074例次,占比20.1%,手术相关信息缺陷455例次,占比9.9%,费用信息缺陷为79例次,占比1.7%;住院过程信息缺陷760例次,占比7.4%。结论:住院病案首页缺陷频次高,需要采取相关措施对住院病案首页填写质量进行控制和管理,从而降低住院病案首页缺陷率,提高病案首页内涵质量。

Purpose:To improve the quality of data on the first page of medical records by analyzing the information defects on the first page of inpatient medical records and standardizing the filling of the first page of medical records.Method:According to a total of 14736 medical records discharged from a hospital from January 1 to November 30,2019,of which a total of 10316 cases were spot-checked,a full-time quality control physician was established in accordance with the relevant provisions of the Quality Specification for the First Data of Inpatient Medical Records(Interim)for the quality inspection and registration on the front page of medical records.Results:There were 4573 cases of defects in 10316 cases,including 1205 cases of basic information defects,accounting for 11.7%,2074 cases of information defects in diagnosis and treatment,accounting for 20.1%,and 455 cases of information related to surgery,accounting for 9.9%,The cost information defect is 79 cases,accounting for 1.7%;the hospitalization information defect is 760 cases,accounting for 7.4%.Conclusion:The frequency of home page defects in hospitalized medical records is high,and relevant measures need to be taken to control and manage the quality of the first page of hospitalized medical records,thereby reducing the defect rate of the first page of inpatient medical records and improving the quality of the connotation of the homepage of medical records.