住院病案首页缺陷分析及校验规则探讨

Analysis of the Defects in the Front Page of Inpatient Medical Records and Discussion on the Checking Rules

目的通过对住院病案首页填写缺陷进行统计分析,列举相应的数据校验规则,以提高医师病案首页填写质量。方法从病案质控系统中导出2019年1月1日-2019年12月31日全部30969份住院病案首页的缺陷登记记录,运用Microsoft Office Excel 2007进行分类统计,回顾性分析住院病案首页填写缺陷,制定数据校验规则。结果住院病案首页的填写缺陷率为11.71%。缺陷频次共计4247次,其中诊疗信息缺陷占54.86%,住院信息缺陷占24.63%,患者基本信息缺陷占20.08%。结论住院病案首页填写缺陷主要为漏填、逻辑错误和填写不规范,从填写完整性、逻辑性、有效性等方面,探讨数据校验规则并嵌入到HIS系统,达到提高住院病案首页质量的目的。

Objective Through the statistics of the defects in the front page of the inpatient medical record,the paper analyzes the contents and causes of the defects,and lists the corresponding data verification rules,so as to improve the quality of the front page of the doctor’s medical record.Methods In the medical record quality control system,the defect registration records of all the front pages of medical records(30969 copies)from January 1,2019 to December 31,2019 are exported,classified statistics are made by using Microsoft Office Excel 2007,defects are filled in the front pages of medical records are analyzed retrospectively,and data verification rules are formulated.Results The defect rate of filling in the front page of 30969 medical records was 11.71%.The frequency of defects was 4247 times in total,including 54.86%of diagnosis and treatment information defects,24.63%of inpatient information defects,and 20.08%of patients’basic information defects.Conclusions The defects of filling in the front page of medical record mainly include omission,logical error and nonstandard filling.From the aspects of completeness,logicality and validity of filling in,the data verification rules are discussed and embedded into his system to improve the quality of the front page of medical record.