对1457份病案首页错误信息的分析

Analysis of Wrong Information on First Page of 1 457 Case Histories

目的 :探讨病案首页错误信息的原因 ,提高数据质量。方法 :采用全军下发的核查软件 ,对 2 0 0 2年 7月— 2 0 0 2年 9月出院患者 145 7份病案首页 ,进行统计核查。结果 :门诊住院填写录入的住院卡片错误信息占总错误的 73.99%;临床医生填写错误信息占 16 .32 %;首页费用错误信息占 1.6 9%,病案编目错误占 8%。结论 :①加强人员培训 ,尤其要学习软件操作及病案首页正确填写的内容 ,统计人员要学习“四版常规”提高质量意识 ;②加强数据监控 ;③健全管理制度 ;④增加软件功能。

Objective: Discussing the cause of improper data on first page of case history and improving the data quality. Methods: Checking 1 457 first pages of case history of patients who left hospital since July to September in 2002, with software provided by army. Results: Wrong information on in-hospital card filled at the time of out-patient department takes up 73.99% of the gross wrong information; wrong information recorded by doctors accounts for 16.32%, improper charge on first page accounts for 1.69%, wrong list accounts for 8%. Conclusion: Firstly, advance training, especially learn the use of software and content on first page. Secondly, strengthen the supervision of data. Thirdly, perfect the administration system. Fourthly, increase the function of software.