某院住院病案首次病程记录书写质量分析

Analysis on the Writing Quality of the First Course Record of Inpatient Records in a Hospital

目的通过对某院首次病程记录书写质量进行分析,为提高病历书写质量提供参考。方法提取某院2022年5月1日-2022年5月31日出院患者住院病案的首次病程记录4240份,由4名取得病案专委会病历书写质量控制培训合栺证书的专职病案质控医师经过统一培训原国家卫生部印发的《病历书写基本规范》及某院《住院病案质量检查表》的首次病程评分标准,对每份首次病程记录进行质量评价。应用Microsoft Office Excel 2013软件收集住院病案首次病程记录评分数据,进行统计分析,计量资料以均数±标准差表示,计数资料采用频数和百分比描述。结果住院病案首次病程记录平均分为(91.81±2.82)分,其中手术科室平均(91.09±2.86)分,非手术科室平均(92.53±2.60)分;住院病案首次病程记录的主要缺陷为病例特点未提炼总结、特点不突出的缺陷率为11.19%,其次为诊疗计划不具体、无针对性的缺陷率为9.59%,鉴别诊断分析未结合患者实际病情的缺陷率为5.41%。结论住院病案首次病程记录书写质量存在病例特点不突出、鉴别诊断与患者实际情况联系不足和诊疗计划不具体等缺陷,还有待进一步提高,医院应重点加强住院医师病历书写相关的法律法规培训,加强首次病程记录书写能力的培养,从而提高医院整体的病历书写水平。

Objectives To provide reference for improving the writing quality of medical records by analyzing the writing quality of the first course records in a hospital.Methods 4240 initial course records of patients discharged from a hospital from May 1st,2022 to May 31st,2022 were extracted.Four full-time medical record quality control physicians who had obtained the certificate of medical record Special Committee for quality control of medical record writing were trained by the first course scoring standard of medical record Writing issued by the former Ministry of Health and the first course of medical record Quality Check Table of a hospital to evaluate the quality of each first course of medical record.Microsoft Office Excel 2013 software was used to collect the scoring data of the first course record of inpatient medical records for statistical analysis.The measurement data was expressed as mean±standard deviation,and the counting data was described by frequency and percentage.Results The average score of the first course record of inpatient records was(91.81±2.82)points,the average score of surgical department was(91.09±2.86)points,the average score of non-surgical department was(92.53±2.60)points.The main defects of the first course record of inpatient records were 11.19%of the patients with unrefined and summarized characteristics and no prominent characteristics,9.59%of the patients with unspecified and untargeted diagnosis and treatment plan,and 5.41%of the patients without combining the actual conditions in the differential diagnosis analysis.Conclusions The writing quality of the first course record of inpatient medical records had some defects,such as the characteristics of medical records were not prominent,the relationship between the differential diagnosis and the actual situation of patients was insufficient,and the diagnosis and treatment plan were not specific,which needed to be further improved.Hospitals should focus on strengthening the legal and regulatory training related to the writing of medical records of residents,and strengthen the cultivation of the writing ability of the first course record,so as to improve the overall writing level of medical records in hospitals.