某医院1200份住院病案首页缺陷分析与对策

Analysis of Defects and Countermeasure Research on Front Page of 1200 Medical Records in a Hospital

目的 通过分析住院病案首页质量,总结住院病案首页缺陷,分析缺陷产生的原因,针对暴露的问题进行对策研究,以便更好的提升住院病案首页填写质量。方法 根据《住院病案首页数据填写质量规范(暂行)》2016版和《病历书写基本规范》2010版的要求,由病案管理委员会精选了5名有丰富经验的临床医师成立了专家质控小组。随机抽取该院2023年1月1日至2023年6月30日出院病案中住院病案首页1200份,分析住院病案首页缺陷情况。结果 1200份住院病案首页中,477份存在缺陷,缺陷率达39.75%。其中,主要诊断缺陷率最高8.50%,其次是主要手术缺陷率8.00%。按照科室统计,重症医学科缺陷率最高51.67%,神经内科缺陷率最低24.73%,整体分析外科系统缺陷高于内科系统。结论 住院病案首页中诊疗填写质量问题仍较突出,其中主要诊断选择错误和名词不规范缺陷率最高,按照科室统计,重症医学科缺陷率最高。应加强病案书写培训和环节质控,建立有效管理机制,进一步提高住院病案首页质量。

Objectives By analyzing the quality of the front page of inpatient medical records,summarizing the defects of the front page of inpatient medical records,analyzing the causes of the defects,and conducting countermeasures for the exposed problems,in order to better improve the filling quality of the front page of inpatient medical records.Methods According to the requirements of the 2016 edition of the"Quality Specification for Data Filling in the Front page of Inpatient Medical Records(Interim)"and the 2010 edition of the"Basic Specification for Writing Medical Records",five experienced clinicians were selected by the medical records Management Committee to set up an expert quality control group.1200 inpatient medical records from January 1st,2023 to June 30th,2023 were randomly selected to analyze the defects of the inpatient medical records.Result Among 1200 inpatient medical records,477 were defective,with a defect rate of 39.75%.Among them,the main diagnosis defect rate was the highest 8.50%,followed by the main surgery defect rate of 8.00%.According to the statistics of the departments,the defect rate of the department of intensive care medicine was the highest 51.67%,and the defect rate of the department of neurology was the lowest 24.73%.Conclusions The quality problems of diagnosis and treatment filling in the front page of inpatient medical records were still prominent,in which the main diagnostic selection errors and nominally irregular defect rates were the highest,and the defect rate of critical care medicine was the highest according to the statistics of the department.We should strengthen the training of medical records writing and the quality control of links,establish an effective management mechanism,and further improve the quality of the front page of inpatient medical records.