骨与软组织肿瘤科住院病案首页问题分析

Analysis of problems on the homepage of inpatient medical records in the department of bone and soft tissue oncology

目的分析某医院骨与软组织肿瘤科住院病案首页问题,为提高住院病案首页质量提供指导。方法回顾性分析某医院骨与软组织肿瘤科2022年4月1日—2023年8月31日住院病案首页2979份,运用Excel统计并记录住院病案首页首次提交时问题发生情况。结果2979份住院病案首页首次提交时存在问题的病案数共1258份,发生率为42.23%。核查1258份存在问题的病案首页,共发现2149条缺陷,其中出院其他诊断错误、出院主要诊断错误、病理诊断错误、其他手术或操作错误、主要手术或操作错误的占比分别为28.71%、22.57%、16.66%、13.49%、10.89%。结论某医院骨与软组织肿瘤科住院病案首页质检前问题较多,应引起重视,可通过对临床医师加强培训、编码员对首页填写问题针对性指导、信息科完善首页提交前逻辑质控、加强绩效考核等降低其发生率。

Objective The purpose of this article is to analyze the problem with the first page of inpatient medical records in the Department of Bone and Soft Tissue Oncology of a certain hospital,in order to provide guidance for improving the quality of the first page of inpatient medical records.Methods A retrospective analysis was conducted on 2979 inpatient medical records from the Department of Bone and Soft Tissue Oncology of a certain hospital from April 1,2022 to August 31,2023.Excel was used to statistically analyze and record the occurrence of problems on the first submission of inpatient medical records.Results A total of 1258 inpatient medical records had issues with the first submission of 2979 inpatient medical records,with an incidence rate of 42.23%.A total of 2149 defects were found on the homepage of 1258 problematic medical records,among which 28.71%,22.57%,16.66%,13.49%,and 10.89%were other diagnostic errors,main diagnostic errors,pathological diagnostic errors,other surgical or operational errors,and main surgical or operational errors,respectively.Conclusion There are many pre quality inspection issues on the first page of inpatient medical records in the Department of Bone and Soft Tissue Oncology of a certain hospital,which should be taken seriously.The incidence rate can be reduced by strengthening training for clinical physicians,providing targeted guidance for coding personnel on filling out problems on the first page,improving pre submission logic quality control in the Information Department,and strengthening performance evaluation.