住院病案首页其他诊断漏填情况分析

Analysis on Leakage of Other Diagnosis on the Front Pages of Hospital Medicial Records

目的通过对某三甲医院住院病案首页诊断填写情况进行检查,明确住院病案首页其他诊断漏填情况。方法普查2017年11月-2018年4月10个病区住院病案首页共5346份,根据原国家卫计委《住院病案首页填写质量规范》中其他诊断的填写要求,由病案质控人员对住院病案首页的出院疾病诊断中其他诊断进行检查。结果住院病案首页漏填其他诊断病案数为1304份,漏填诊断个数为1380个。外科系统科室其他诊断漏填率高于内科系统科室。颅底神经肿瘤病区漏填率最高,达34.66%。82.1%为住院期间新发生或新发现的疾病和异常所见。结论临床医师出院诊断填写忽略检查检验和会诊结果,漏填手术后并发症。同时医师的责任心和医院病案质量管理不到位均影响着其他诊断填写的完整性。

Objective Through checking the filling status of the first page of the discharged medical records of a third grade hospital,we should make clear the other diagnosis. Methods A total of 5346 medical records were diagnosed in ten disease area from November 2017 to April 2018. According to the requirements of other diagnosis in the front pages of the hospital medical records, the medical records quality control personnel examined the diagnosis of the hospital disease on the front pages of the hospital medical records.Results The number of omitting cases was 1304, and the number of missed diagnosis was1380. Other diagnostic and filling rates in surgical departments were higher than those in internal medicine departments. The rate of leakage was highest in the cranial nerve tumor area, reaching 34.66%. 82.1% new or newly discovered diseases and anomalies seen during hospitalization. Conclusions The clinician discharged the diagnosis neglected the examination and consultation results, and missed the postoperative complications. At the same time, the doctor’s sense of responsibility and the quality management of hospital medical records were not in place, which affected the completeness of other diagnosis.