住院病案首页填写问题现状与研究进展

The Current Situation and Research Progress in Filling Out the Front Page of Inpatient Medical Records

目的检索2018年-2022年住院病案首页相关文献,总结现阶段我国医院住院病案首页填写存在的问题,分析填写缺陷原因,总结质量控制方法,提出管理策略,为提高住院病案首页填写质量提供参考。方法基于中国知识资源总库(CNKI),以“住院病案首页”或“缺陷”为检索词,检索2018年-2022年相关文献,并对其中有代表性的文献进行分析与总结。结果共纳入140篇相关文献,其中2022年发文量最多,文献主要集中收录于《中国病案》。检索文献共涉及130496份病案,20322份病案(15.57%)存在缺陷,其中40.28%为工作单位、地址、电话、邮编未填写,28.83%为主要诊断填写错误。结论住院病案首页填写质量重视度低、部门职权分工与信息系统不完善、缺少正规培训是住院病案首页填写错误的主要原因。对出现的问题提出针对性措施,可有效改善住院病案首页质量。

Objectives This study aims to retrieve relevant literature on the front page of inpatient medical records from 2018 to 2022,summarize the problems in filling out the front page of inpatient medical records in Chinese hospitals at present,analyze the reasons for filling out defects,summarize quality control methods,and propose management strategies,so as to provide a reference for improving the quality of filling out the front page of medical records.Methods Based on the China National Knowledge Infrastructure(CNKI),relevant literature from 2018 to 2022 was searched using the search terms"front page of hospitalization medical records"or"defects".Representative literatures were analyzed and summarized.Results Through literature review and summary,140 relevant literatures were included,with the highest number of publications in 2022,mainly concentrated in the Chinese Medical Records.The retrieved literature involved a total of 130,496 medical records,and 20,322 medical records(15.57%)had defects.Among them,40.28%were not filled in the work unit,address,phone number,and zip code,and 28.83%were incorrectly filled in the main diagnosis.Conclusions The main reasons for errors in filling out the first page of inpatient medical records are low emphasis on quality,incomplete division of departmental powers and information systems,and lack of formal training.Proposing targeted measures for the problems that arise can effectively improve the quality of the medical record front page.