病案首页中手术科室对内科疾病诊断遗漏填写分析  

Analysis on Surgery Department Missing Disease Diagnosis of Internal Medicine in Front Page of Medical Records

作　　者：孙鹏[1] 李卫红[1] 贾丽君[1] 

机构地区：[1]首都医科大学附属北京同仁医院

出　　处：《中国病案》2011年第7期26-27,共2页Chinese Medical Record

摘　　要：目的对我院2010年29,183份例手术病案首页诊断填写审核,以便提高病案首页诊断的完整性。方法对3581例漏填诊断的病案进行统计、分析。结果发现高血压等内科疾病诊断漏填比较严重。结论针对病案首页漏填的问题采取相应措施,减少以后此类问题的出现。Objectives to improve the completeness of diagnosis filling in front page of medical records.Methods Filling quality of hospitalization diagnosis in front page of 29183 medical records had surgery are examined in our hospital.Have a statistically analysis on 3581 medical records that miss hospitalization diagnosis.Results It turned out that the missing filling situation of disease diagnosis of internal medicine like hypertension are more serious.Conclusions We should adopt relevant countermeasures in view of the missing filling problems in front page of medical records,in order to reduce the appearance of these kinds of problems.

关 键 词：病案首页 手术科室 遗漏诊断 

分 类 号：R197.3[医药卫生—卫生事业管理]