住院病案首页质量管理问题及对策

Problems and Countermeasures of Quality Management of the Front Page of Inpatient Medical Records

目的分析住院病案首页质量管理现状,发现问题并提出针对性解决对策,为完善住院病案首页质量管理工作提供参考及依据。方法抽取2021年1月1日至2022年12月31日某医院各临床科室病案10524份,包括2021年4923份与2022年5601份,比较2021年与2022年住院病案首页缺陷(漏填、错填)情况、住院病案首页缺陷类别(患者基本信息、住院过程信息以及诊疗信息),分析住院病案首页缺陷类别构成比。结果2022年住院病案首页漏填率、错填率及缺陷总发生率低于2021年,差异有统计学意义(P<0.05);缺陷份数2181份,缺陷项目2882项,其中缺陷构成比最高的是诊疗信息74.05%,其次是住院过程信息13.08%,患者基本信息12.87%;漏填率最高的是颅脑损伤昏迷时间55.56%,其次是新生儿出生体重2.14%;错填率最高的是手术及操作7.52%,其次是主要诊断5.25%;缺陷率最高的是颅脑损伤昏迷时间55.56%,其次是手术及操作9.06%;2022年住院病案首页患者基本信息、住院过程信息、诊疗信息缺陷发生率低于2021年,差异有统计学意义(P<0.05)。结论住院病案首页质量管理并不理想,可通过健全相关管理制度、建立住院病案首页质控网络、改进管理方法、构建诊疗信息库、增加病案与临床交流途径等对策减少住院病案首页缺陷,提高住院病案首页质量。

Objective To analyze the current situation of quality management of the front page of inpatient medical records,identify the problems and propose targeted solutions,so as to provide reference and basis for improving quality management of the front page of inpatient medical records.Methods A total of 10,524 medical records were selected from different clinical departments in the hospital from January 1st,2021 to December 31st,2022,including 4,923 records in 2021 and 5,601 records in 2022.The defects(missed filling and wrong filling)on the front page of inpatient medical records and the types of defects(patient basic information,information during hospitalization and information about diagnosis and treatment)in 2021 and 2022 were compared.The composition ratios of defect categories on the front page of inpatient medical records were analyzed.Results The rates of missed filling and wrong filling,and the total incidence of defects on the front page of inpatient medical records in 2022were lower than those in 2021(P<0.05).There were 2,181 medical records with defects on the front page,and there were 2,882 defective items.Among them,the proportion of defects in diagnosis and treatment information was the highest(74.05%),followed by defects in information during hospitalization(13.08%)and defects in patient basic information(12.87%).The missed filling rate of comatose time in craniocerebral injury was the highest(55.56%),followed by neonatal birth weight(2.14%).The wrong filling rate of operation and procedures was the highest(7.52%),followed by primary diagnosis(5.25%).The defect rate of comatose time in craniocerebral injury was the highest(55.56%),followed by operation and procedures(9.06%).The incidence rates of defects in patient basic information,information during hospitalization and information about diagnosis and treatment on the front page of inpatient medical records in 2022 were lower than those in 2021(P<0.05).Conclusions The quality management of the front page of inpatient medical records was not ideal.Measures such as strengthening training,improving relevant management systems,establishing a quality control network for the front page of inpatient medical records,improving management methods,building a diagnosis and treatment information database,and increasing communication channels between medical records and clinical practice could be taken to reduce defects in the front page of inpatient medical records and improve the front page quality of inpatient medical records.