某医院1360份住院病案首页缺陷分析与对策

Analysis of Defects and Countermeasure Research on Front Page of 1360 Medical Records in a Hospital

目的通过分析住院病案首页质量,总结住院病案首页缺陷,分析不同缺陷产生的原因,针对暴露的问题进行对策研究。方法根据《住院病案首页数据填写质量规范(暂行)》2016版和《病历书写基本规范》2010版的要求,随机抽取某院2018年1月1日至2018年10月31日出院病案中住院病案首页1360份,分析住院病案首页缺陷情况。结果分析的1360份病案中,累计缺陷份数为544份,累计缺陷率40%。按照科室统计,外科系统整体缺陷率高于内科系统。结论住院病案首页质量问题仍较突出,缺陷原因不尽相同,不同科室的住院病案首页缺陷情况也不一致,医院主管部门及临床科室应充分重视,建立有效的管理机制,有针对性地进行管理与培训,从而提高住院病案首页质量。

Objective To analyze the quality of the front page of inpatient medical records,summarize the defects and analyze the causes of different defects,and study the countermeasures for the exposed problems.Methods According to the requirements of"Quality Specification for Filling in Front Page Data(Temporary)"(2016)and"Medical Record Writing Standard 2010",1360 front pages of discharged medical records from January 1 to October 31,2018 were randomly selected to analyze the defects of the front page.Results Statistical analysis of the front page of medical records showed that 544 of the 1360 medical records were defective,with a cumulative defect rate of 40%.According to department statistics,the overall defect rate of the surgical system is higher than that of the internal system.Conclusion The quality of the front page of medical records is still prominent.The causes of defects are not the same,and the defects of the front page of different departments are not the same,so the hospital administrative departments and clinical departments should pay full attention and establish effective management mechanism to carry out targeted management and training,so as to improve the quality of the front page.