4414份住院病案首页专项质控分析

Analysis of Special Quality Control on the Front Page of 4414 Hospitalized Medical Records

目的 通过对某院住院病案首页诊疗信息填写情况进行抽查并对结果进行统计汇总,分析存在缺陷及产生原因,提出改进措施,提高病案首页质量。方法 根据原卫生部《病案首页部分项目填写说明》及国家卫生计生委办公厅《住院病案首页数据填写质量规范(暂行)》(2016年版)的要求,对某院2020年1月1日-12月31日出院病案,16个临床科室每月随机抽取约20%的归档病案,大科室30份,中小科室10-20份不等,共随机抽取4414份住院病案首页,针对住院病案首页中诊疗信息项目进行专项质控。结果 抽查的4414份病案中,共有231份住院病案首页存在缺陷,缺陷率5.23%,缺陷率居前5位的分别是神经骨外科、普外科、产科、妇科和泌尿外科。缺陷内容以主要手术及操作填写错误、离院方式填写错误、主要诊断填写错误为最多,占到总缺陷份数的66.24%。结论 住院病案首页诊疗信息尤其是手术科室填写质量有待提高,应加强临床医师特别是外科医师的住院病案首页规范填写培训力度,不断完善系统软件功能,加强编码人才队伍建设等,提升住院病案首页诊疗信息填写质量。

Objective Through random inspections on the diagnosis and treatment information filling on the front page of the medical records for the patients who were discharged from a certain hospital and statistical collection of the results,the defects and causes are analyzed to find improvement measures,so as to further enhance the quality of the front page of the medical records.Methods 4414 cases of medical records for the patients who were discharged from a certain hospital from January 1,2020 to December 31 were taken random inspections to carry out special quality control for the items of diagnosis and treatment information on the front page,according to the requirements of the Filling in Instructions of Partial Items of New Edition of Medical Records published by the Ministry of Health,and the Inpatient Case Home Data Fill in Quality Specification(Temporary)(2016) published by the General Office of National Health and Family Planning Commission.(About 20% of the archived medical records are randomly selected from 16 clinical departments every month,including 30 in large departments and 10-20 in small and medium-sized departments.).Results Among the 4414 cases of medical records,231 cases have defects on the front pages,with a defect rate of 5.23%,and the departments of neurosurgery and orthopedic surgery,general surgery,obstetrics,gynecology and urology ranked as the top five departments.The most common defects are filling out errors in main surgery and operation,in the way of leaving hospital,and in main diagnosis,accounting for 66.24% of the total defects of medical records.Conclusion It is necessary to improve the filling quality of diagnosis and treatment information on the front page of the medical records,especially the filling quality of surgery departments which need to fill information,so the hospital shall strengthen the training of standard filling for clinicians,especially surgeons,continuously improve the function of system and software,establish a long-term mechanism for the quality control of the front page,and strengthen the construction of coding talents,so as to improve the quality of filling in diagnosis and treatment information on the front page of medical records.