病案首页书写缺陷分析及解决对策

Analysis of the Writing Defects on the Front Page of Medical Records and Solutions

目的调查病案首页书写存在的问题,加强病案质量管理,提高病案首页数据的准确性。方法对某院2018年1月～6月病案首页填写情况进行调查,统计缺陷项目及存在的问题。结果终末质控归档病案首页48249份,项目漏填率为2.40%;错填率整体较高,死亡与尸检错填率最高,为77.20%,其次为损伤中毒的外部原因(46.00%)、药物过敏(31.89%)、手术切口愈合等级(26.18%)等。每份病例首页均存在填写问题,且问题形式多种多样。结论医疗机构应加强病案质量管理,医务人员应规范填写首页,降低人为因素造成的错填率,提高病案首页信息质量。

Objective To investigate the problems existing in the first page of the medical record, strengthen the quality management of the medical record, and improve the accuracy of the data on the front page of the medical record.Methods Investigate the filling of the first page of the medical record from January to June 2018 in a hospital, and count the defective items and existing problems. Results The final quality control archived medical records were 48,249 on the first page, and the project leakage rate was 2.40%. The overall error rate was higher, and the death and autopsy rate was 77.20%, followed by external causes of damage poisoning(46.00%). Drug allergy(31.89%), surgical incision healing grade(26.18%). There is a question of filling in the front page of each case, and the form of the problem is various.Conclusion Medical institutions should strengthen the quality management of medical records. Medical staff should standardize the homepage, reduce the rate of incorrect filling caused by human factors,and improve the quality of medical records.