肿瘤专科医院病案内涵缺陷分析及对策

Analysis of the Connotation Defects of Medical Records in Cancer Hospitals and Countermeasures

目的通过对肿瘤专科病案终末质控了解病案内涵质量现存问题,反馈临床并指导改进,提升病案内涵质量。方法抽取天津医科大学肿瘤医院于2023年1—12月出院患者的病案29820份,组织专家与质检员共同依据检查标准开展针对病案书写内容进行分析评价,运用Excel 2003表格归纳整理数据,对病案质量缺陷分布情况进行描述性统计分析。结果共抽检病历29820份,缺陷条目共计58749条,排在前5位的缺陷条目为:首次病程记录照搬复制未归纳提炼、术前讨论记录内容缺陷、手术记录内容缺项或不规范、知情同意书缺项或不规范、出院记录诊疗经过记录不规范或过于简单,占比分别为13.16%、7.34%、5.53%、5.17%、4.90%。结论本院病历书写仍存在较多缺陷,主要集中在首次病程记录、围术期记录、知情同意书、出院记录等。需采取相应举措,持续改进病案内涵质量,降低病历内涵缺陷率。

Objective To understand the existing problems in the quality of medical records in oncology specialty through end-stage quality control,provide feedback to clinical practice,and guide improvement to enhance the quality of medical records.Methods A total of 29820 medical records of patients discharged from Tianjin Medical University Cancer Hospital from January to December 2023 were selected as the research objects.Experts and quality inspectors were organized to analyze and evaluate the content of medical records based on the examination standards.Excel 2003 table was used to summarize and sort out the data,and descriptive statistical analysis was carried out on the distribution of quality defects in medical records.Results A total of 29820 medical records were randomly selected for examination,with a total of 58749 defective items.The top five defective items were:copying the first medical course record without induction and extraction,defects in preoperative discussion records,missing or non-standard surgical records,missing or non-standard informed consent forms,and non-standard or overly simple diagnosis and treatment process records in discharge records,accounting for 13.16%,7.34%,5.53%,5.17%,and 4.90%,respectively.Conclusion There are still many deficiencies in the writing of medical records in this hospital,mainly concentrated in the first course of illness records,perioperative records,informed consent forms,discharge records,etc.Corresponding measures need to be taken to continuously improve the quality of medical records and reduce the defect rate of medical records.