1550份住院病案首页离院方式的缺陷分析与改进措施

Defect Analysis and Improvement Measures of the Way of Leaving Hospital on the Home Page of 1550 Medical Records

目的分析某医院住院病案首页离院方式填写的质量情况,并根据存在的错误问题,提出整改措施。方法从某院2018年1月1日-2018年6月30日17761份出院病案中抽查1550份纸质病案,对每份住院病案首页的离院方式的填写质量进行检查,并将错误问题汇总、归类、统计分析、总结。结果 1550份住院病案首页中,离院方式填写错误共58例,缺陷率3.74%,其中错误最高的是'其他(代码为9)'填写错误6例,缺陷率100%;其次是'医嘱转社区卫生服务机构/乡镇卫生院(代码为3)',填写错误3例,缺陷率27.27%;最低是医嘱离院(代码为1)填写错误32例,缺陷率2.28%。结论加强住院病案首页'离院方式'指标培训和质量控制,提高住院病案首页的质量水平,为医院管理层提供客观而准确的数据支持。

Objective To analyze the quality of filling out the way of leaving hospital on the first page of inpatient medical record in a hospital,and puts forward some rectification measures according to the existing error problems.Methods 1550 paper medical records were checked from 17761 discharged medical records from January 1,2018 to June 30,2018.The filling quality of the way of leaving hospital on the first page of each medical record was checked and the error problems were summarized,classified,statistically analyzed and summarized.Results Of the 1550 medical records,58 cases were misfilled in the way of leaving the hospital,and the defect rate was 3.74%.Among them,the highest error is'other(code 9)'.There were 6 cases of error,the defect rate is 100%;Secondly,'the doctor’s order was transferred to the community health service organization/township health center(code 3)'.There were 3 cases of error,and the defect rate was 27.27%.The lowest was 32 cases of error filling out of hospital(code 1),and the defect rate was 2.28%.Conclusion Strengthen the training and quality control of the index of'way of leaving hospital'on the home page of medical records,improve the quality level of the home page of medical records,and provide objective and accurate data support for hospital management.