重症医学科住院病案首页填写缺陷分析

Analysis on Defects of the Front Pages of Medical Records in Department of Critical Care Medicine

目的分析某院重症医学科住院病案首页填写缺陷,以加强临床医师住院病案首页填写正确性,强调科室住院病案首页填写质控的重要性。方法对2019年1月1日-2019年12月31日某院所有重症医学科住院病案首页进行质控,将病案首页缺陷进行总结分析。结果共有住院病案397份,病案首页填写缺陷(175例)共250个缺陷,主要诊断45个(18%)、次要诊断68个(27.2%)、入院病情19个(7.6%)、中毒损伤外部原因1全(0.4%)、病理12个(4.8%)、疑难个2(0.8%)、药物过敏5个(2.0%)、抢救次数4个(1.6%)、手术3个(1.2%)、伤口愈合18个(7.2%)、操作64个(25.6%)、离院方式7个(2.8%)、转入出ICU时间2个(0.8%)。住院病案首页填写总缺陷率43%,1个缺陷65.8%,2个缺陷26.9%,3个缺陷7.5%。结论重症医学科住院病案首页填写的缺陷内容很多,应加强住院病案首页归档前的科室质控,进一步提高病案首页质量。

Objectives To enhance the quality of the front page of medical records in department of critical care medicine through analyzing the defects emerging while filling in the front pages by clinicians.Methods We reviewed 397 discharge medical records in the front page of hospital medical records and analyzed the defects in all critical care patients between January 1st,2019 to December 31st,2019.The defects on the front page of the hospital medical records were summarized and analyzed according to the following factors:main diagnosis,secondary diagnosis,condition of admission,cause of injury and poisoning,pathology,clinic difficult disease,number of rescues,drug allergy,blood type,operation,procedures,way of leaving hospital,and time of entering and leaving ICU.Results There were 397 discharge medical records,among them 175 cases were found having flawed front page.The defects were as following:main diagnostic 45(18%),secondary diagnostic 68(27.2%),admitted to hospital condition of 19(7.6%),external reasons of poisoning and trauma 1(0.4%),pathologic 12(4.8%),clinic difficult disease 2(0.8%),rescue times 4(1.6%),allergic reactions to drugs 5(2.0%)blood type 0(0%)operation 4(1.6%),wound healing 18(7.2%),procedures 64(25.6%),departure from the hospital way 7(2.8%),ICU transfer time 2(0.8%).The total defects in filling of the front pages was 43%,one defect was 65.8%,two defects were 26.9%,three defects were 7.5%.Conclusions Filling in the first page of the medical records of critically ill patients was complex task,and the defects of the first page of the medical records couldn't be ignored before archiving.The quality control of the department before the first page of medical records was not to be ignored.