住院病案疾病诊断的书写缺陷分析  

An Analysis of Deficiencies of Diagnoses in the Medical Records of the Inpatients

作　　者：王宇红[1] 冯家琳[1] 林少晖[1] 王辉[1] 林武红[1] 

机构地区：[1]汕头大学医学院第二附属医院信息科,汕头市515041

出　　处：《中国病案》2006年第10期23-25,共3页Chinese Medical Record

摘　　要：目的调查临床常见的疾病诊断书写缺陷,探讨改进方法。方法参照“广东省病历书写规范”,检查我院2005年共18005份出院病案的疾病诊断书写情况。结果(1)主要诊断选择错误：(2)疾病诊断名称,手术操作名称书写不完整；(3)损伤和中毒外部原因漏填或填写不具体。结论重视疾病诊断的正确书写,有利于提高病案的信息价值。Objective To investigate the clinic diagnostic deficiencies in the medical records and discuss the mending methods. Methods According to the writing Criterion of Medical Record of Guangdong Province, Diagnostic inspect were carried out on 18005 records of inpatients from January to December in 2005. Results Choosing the unsuitable chief diagnosis; Filling in unreasonable disease or operative terms; Leaking or unthinking to fill the exterior causes of trauma and poison. Conclusions Paying attention to filling in the clinic diagnosis will benefit to increase the information value of medical records.

关 键 词：疾病诊断 病案 ICD-10 信息价值 

分 类 号：R197.3[医药卫生—卫生事业管理]