某三级皮肤专科医院住院病案首页填写调查与分析

Investigation and Analysis of Filling in the Homepage of Inpatient Medical Records in a Tertiary Dermatology Hospital

目的了解某三级皮肤病医院病案首页数据填写存在的问题,查找原因并为制订行之有效的干预措施。方法病案室抽取2020年1—12月期间1614份住院病案首页进行质量监控。结果病案首页总体缺陷率为69.46%,缺陷频次从高到低依次为:诊断信息缺陷频次987个,占比61.15%;患者基本信息缺陷频次683个,占比42.32%;住院过程信息缺陷频次489个,占比30.29%。结论该院病案首页填写质量不容乐观,需各级部门共同努力,还应加强管理,严格执行三级质控制度,强化医师培训和责任心的培养,完善奖惩制度,提高病案首页填写质量,为DRGs实施打下坚实基础。

Objective To understand the problems existing in filling data on the first page of medical records in a tertiary dermatology hospital,find out the reasons and formulate effective intervention measures.Methods The medical record room selected 1614 inpatient medical records from January to December 2020 for quality monitoring.Results The overall defect rate of the first page of medical records was 69.46%,and the frequency of defects from high to low was as follows:the frequency of diagnostic information defects was 987,accounting for 61.15%.The frequency of patients'basic information defects was 683,accounting for 42.32%.The frequency of information defects in the hospitalization process was 489,accounting for 30.29%.Conclusion The quality of filling in the homepage of medical records in the hospital is not optimistic,and the joint efforts of departments at all levels are needed.It is also necessary to strengthen management,strictly implement the three-level quality control system,strengthen the training of physicians and the cultivation of sense of responsibility,improve the reward and punishment system,and improve the quality of filling in the first page of medical records,so as to lay a solid foundation for the implementation of DRGs.