住院病案首页病情信息填写质量的缺陷分析及质控管理

Defect Analysis and Quality Control Management of Filling Quality of Disease Information on the Homepages of Inpatient Medical Records

目的分析住院病案首页病情信息填写质量的缺陷原因并对质控管理提出整改意见。方法调取惠州市中医医院2021年1—6月间3349例住院病案首页作为研究资料展开回顾性分析,以2016年版《住院病案首页数据质量管理与控制指标》为标准,观察住院病案首页病情信息填写占比、填写正确率及填写错误案例原因。结果3349例住院病案首页,入院病情选项1“有”3050例,占比91.07%(3050/3349),其次为选项3“情况不明”199例,占比5.94%(199/3349),选项2“临床未明确”62例,占比1.85%(62/3349),最少为选项4“无”38例,占比1.13%(38/3349);入院病情填写正确病案2877例,占比85.91%(2877/3349),其中选项1“有”填写正确2695例,占总正确病例的93.67%(2695/2877),占总填写为“有”病例的88.36%(2695/3050),选项2“临床未明确”填写正确38例,占总正确病例的1.32%(38/2877),占总填写为“临床未明确”病例的61.29%(38/62),选项3“情况不明”填写正确116例,占总正确病例的4.03%(116/2877),占总填写为“情况不明”病例的58.29%(116/199),选项4“无”填写正确28例,占总正确病例的0.97%(28/2877),占总填写为“无”病例的73.68%(28/38);填写错误病案472例,占比14.09%(472/3349),原因有疾病理解错误356例,占比75.42%(356/472),问诊时漏诊63例,占比13.35%(63/472),书写错误41例,占比8.69%(41/472),填写标准理解错误11例,占比2.33%(11/472),隐瞒事实1例,占比0.21%(1/472)。结论住院病案首页病情信息填写质量的缺陷主要来自于对疾病认知不全面及问诊漏诊,因此应加强相关人员疾病相关知识培训以避免病情填写错误。

Objective To analyze the causes of defects in the filling quality of disease information on the homepages of inpatient medical records,and to propose the rectification suggestions for quality control management.Methods The homepages of medical records of 3349 inpatients in the hospital between January and June 2021 were retrieved as research data for retrospective analysis.Based on the 2016 edition of Data Quality Management and Control Indicators on the Homepages of Inpatient Medical Records,the proportion of filling of disease information on the homepages of inpatient medical records,correct rate of filling and reasons of filling error cases were observed.Results On the homepages of 3349 inpatient medical records,there were 3050 cases of admission disease condition option 1 yes,accounting for 91.07%(3050/3349),followed by option 3 unknown for 199 cases,accounting for 5.94%(199/3349),option 2 clinically unclear for 62 cases,accounting for 1.85%(62/3349),and at least option 4 none for 38 cases,accounting for 1.13%(38/3349).2877 cases were filled with correct admission disease condition,accounting for 85.91%(2877/3349),including 2695 cases of correct filling of option 1 yes,accounting for 93.67%(2695/2877)of the total correct cases,accounting for 88.36%(2695/3050)of the total filling cases in yes,38 cases of correct filling of option 2 clinically unclear,accounting for 1.32%(38/2877)of the total correct cases,61.29%(38/62)of the total filling cases in clinically unclear,116 cases of correct filling of option 3 unknown,accounting for 4.03%(116/2877)of the total correct cases,accounting for 58.29%(116/199)of the total filling cases in unknown and 28 cases of correct filling of option 4 none,accounting for 0.97%(28/2877)of the total correct cases,accounting for 73.68%(28/38)of the total filling cases in none.There were 472 cases filled in wrong medical records,accounting for 14.09%(472/3349),among which 356 cases were caused by disease understanding errors,accounting for 75.42%(356/472),63 cases were caused by missed diagnosis in inquiries,accounting for 13.35%(63/472),41 cases caused by written errors,accounting for 8.69%(41/472),11 cases caused by misunderstanding of filling standards,accounting for 2.33%(11/472)and 1 case caused by concealment of facts,accounting for 0.21%(1/472).Conclusion The defects in filling quality of disease information on the homepages of inpatient medical records are mainly due to incomplete cognition of diseases and missed diagnosis in inquiries.Therefore,it is necessary to strengthen the training of relevant personnel on disease related knowledge so as to avoid filling errors.