病案首页缺陷对统计信息质量的影响  

The Influence of Writing Defects on the First Page of Medical Records on the Quality of Statistical Information

作　　者：陈合辉[1] 冯信坚[1] 

机构地区：[1]中山大学附属第三医院,广东广州510630

出　　处：《临床医学工程》2012年第4期639-640,共2页Clinical Medicine & Engineering

摘　　要：目的针对病案首页缺陷提出相应的对策,进一步提高信息统计质量。方法按2001年卫生部颁发的病案首页填写标准,对某院病案首页信息填写进行质控、检查分析。结果检查37189份病案首页,2026份存在缺陷,归纳影响病案首页填写质量的因素。结论为了提高病案首页填写的正确性,需要临床医师、病案管理人员、医疗质量管理部门共同努力,从而提高病案信息的利用价值。Objective To put forward the corresponding countermeasures for the writing defects on the first page of medical records and improve the quality of statistical information.Methods The information writing on the first page of medical records in a hospital was checked and analyzed.Results Among 37 189 cases of medical records,2 026 cases had writing defects.The factors of influencing medical record quality were summerized.Conclusions In order to improve the writing accuracy of the first page of medical records,co-work is quite necessary for clinicians,medical record managers and hospital management section to enhance the utility value of medical record information.

关 键 词：病案首页 统计信息 准确性 

分 类 号：R195.1[医药卫生—卫生统计学]