某新成立三级民营医院病案质量分析

Analysis on the Quality of Medical Records in a Newly Established Third-Tier Private Hospital

目的了解该新成立民营医院自2019年9月25日开诊以来住院病案首页填写的质量与内涵质量,并协助临床一线人员更好的完成住院病案首页填写与病历书写的工作。方法对2019年9月5日-2019年12月31日该院骨科,儿科,康复科,创伤ICU,老年医学科5个科室12个病区出院已归档的住院病案首页进行普查,按缺项、漏项、错填项、住院病案首页主要诊断选择错误问题以及手术操作名称填写不规范问题进行分类并讨论分析并随机抽取其中200份出院病案进行内涵质量检查。结果共检查996份病案,其中住院病案首页缺陷病案193份,其中缺项占比2.6%、漏项占比3.3%、错填项占比5.2%、主要诊断选择错误占比2.5%、手术操作名称填写不规范问题占比5.7%、缺陷病案占总病案数为19.3%;随机抽取的200份出院病案中,甲级率94.5%、乙级率4.5%、丙级率1%。结论住院病案首页缺陷占比相对较低,主要诊断填写错误问题同手术操作名称填写不规范问题仍有发生。仍需持续加强对住院病案首页的填写和质控工作,对于已经出现的问题加强整改,提升今后出院病案的总体质量。

Objective To understand the quality and connotation of filling in the first page of hospitalization medical records in the newly established private hospital since its opening on September 25,2019,and to assist clinical front-line staff to better complete the work of filling in the first page of hospitalization medical records and writing medical records.Methods From September 5,2019 to December 31,2019,a general survey was conducted on the first page of hospitalized medical records that had been filed in 12 wards of 5 departments of orthopedics,pediatrics,rehabilitation and trauma ICU,geriatrics in this hospital,and classified and analyzed according to missing items,omitted items,misfilled items,main problems of wrong diagnosis on the first page of hospitalized medical records and non-standard filling in operation names.Among them,200 medical records were randomly selected for connotation quality examination.Results A total of 996 medical records were examined,of which 193 were defective on the first page of hospitalization records,of which 2.6%were missing items,3.3%were missing items,5.2%were misfilled items,2.5%were major diagnostic errors,5.7%were irregularities in filling in operation names,and 19.3%were defective medical records.Among the 200 medical records randomly selected,the rate of grade A was 94.5%,the rate of grade B was 4.5%,and the rate of grade C was 1%.Conclusion The proportion of defects on the first page of hospitalization medical records is relatively low,and the main problems of wrong diagnosis and non-standard operation names still occur.It is still necessary to continuously strengthen the filling and quality control of the first page of hospitalization medical records,strengthen rectification and reform of the existing problems,and improve the overall quality of discharge medical records in the future.