某二级医院近5年外科死亡住院病案首页缺陷分析

Analysis of Defects on First Page of Surgical Death Cases in a Secondary Hospital in Recent 5 Years

目的通过核查二级医院外科死亡住院病案首页死亡原因及主要诊断选择的错误,进而提高外科死亡病案首页质量。方法于某院数据库中提取2015年1月1日-2019年12月31所有外科死亡住院病案共计238份,根据《住院病案首页数据填写质量规范(暂行)》的标准,对死亡住院病案首页进行专项检查,使用Excel表格进行统计分析。结果 238份死亡住院病案首页中缺陷病案126份,占52.94%,其中主要诊断及编码错误的病案数为60份,占缺陷病案的47.62%;172份因恶性肿瘤死亡的住院病案首页中有24份主要诊断选择错误;手术、操作的缺陷有39份。结论某二级医院的外科死亡住院病案首页缺陷的原因集中表现在主要诊断及其编码选择上,加强死亡住院病案首页质控管理,定期对临床医师进行住院病案首页填写规范化培训、增加编码及质控人员继续教育、优化信息系统,以提高住院病案首页质量。

Objective To improve the quality of the first page of surgical death cases in secondary hospitals by checking the causes of death on the first page of surgical death cases and the errors in major diagnostic choices.Methods According to thestandard of"Quality Specification for Inpatient Medical Record Home Page Data Filling(Provisional)",238 surgical death medical records were extracted from January 1,2015 to December 31,2019 after the database was changed,and special examination was carried out on the home page of medical records.Results There were 126 cases with defects,accounting for 52.94%of the total.Among them,60 cases were diagnosed and coded incorrectly,accounting for 47.62%of the total.Among the 172 hospitalized medical records died of malignant tumor,24 were misdiagnosed and 39 had defects in operation.Conclusion The causes of defects on the front page of medical records were mainly manifested in the errors in the main diagnosis and coding selection.To improve the quality of the first page of death medical records,we should strengthen the quality control management of the first page of death medical records,carry out regular standardized training for clinicians to fill in the first page of death medical records,increase opportunities for quality control personnel to re-learn and optimize information systems.