某院住院病案首页填写质量分析

Quality Analysis of Filling in the First Page of Medical Records in a Hospital

目的通过检查某院住院病案首页填写质量,进一步提高某院住院病案首页填写质量。方法对某院2020年1月1日-2020年6月30日所有的出院病案共5629份进行终末质量监控,统计分析住院病案首页填写存在的问题,并分析原因及提出解决问题的办法。结果住院病案首页存在缺陷的病案有648份,总缺陷率为11.51%。住院病案首页问题共计发生缺陷829频次,其中患者基本信息缺陷219频次,缺陷占比26.42%;医疗信息缺陷414频次,缺陷占比49.94%;住院过程信息缺陷167频次,缺陷占比20.14%;费用信息缺陷29频次,缺陷占比3.5%。结论该院住院病案首页填写总缺陷率较高,填写质量不好,医院应加强对医师的住院病案首页正确填写培训力度和编码员的专业技能培训,构建完善的病案质控体系,及时发现住院病案首页问题,提升住院病案首页填写质量。

Objective By checking the filling quality of the first page of inpatient medical records in a hospital,the filling quality of the first page of inpatient medical records in a hospital can be further improved.Methods A total of 5629 discharge medical records from a hospital from January 1,2020 to June 30,2020 were monitored for the final quality.The problems existing in the first page of the inpatient medical records were statistically analyzed,and the causes were analyzed and the solutions were proposed.Results There were 648 inpatient medical records with defects in the first page,and the total defect rate was 11.51%.A total of 829 defects occurred in the first page of inpatient medical records,among which 219 defects occurred in the basic information of patients,accounting for 26.42%.414 medical information defects,accounting for 49.94%;Information defects during hospitalization were 167 times,accounting for 20.14%;There were 29 defects in expense information,accounting for 3.5%.Conclusion Hospital inpatient medical record home page to fill in the total defect rate is higher,complete quality is not good,the hospital should strengthen the hospital medical record home page fill in the right of doctor training and coder,professional skills training and continuing education,build perfect medical record quality control system,discover the problem of hospital medical record home page,improving the quality of hospital medical record home page to fill out.