病案首页病人基本信息常见问题分析及对策  

Analysis of problems for basic information of medical record homepage and countermeasure

作　　者：庄伟清[1] 蓬勃[1] 邹虹[1] 

机构地区：[1]北京大学深圳医院住院登记处,广东518036

出　　处：《齐齐哈尔医学院学报》2013年第20期3032-3033,共2页Journal of Qiqihar Medical University

摘　　要：目的为提高病案首页质量,更好地为住院患者服务。方法对2012年5—6月3 205份病案首页基本信息存在问题进行统计分析。结果分析原因有四方面:(1)病人提供信息有误;(2)工作人员责任心欠缺;(3)医保卡信息有误;(4)制度不完善。针对以上问题实施相应对策后对2012年9—10月3 530份病案首页缺陷率进行对照。缺陷率自12.9%下降到2%,差异有显著性(P<0.01)。结论通过加强与患者沟通、提供人性化服务、完善相关制度、强化医务人员工作责任心,可以提高病案首页质量,从而提高服务质量。Objective To improve the quality of medical record homepage to provide better helps for hospitalized patients. Methods According to the basic information of the 3205 medical record from May to June in 2012, problems were statistically analyzed. Results Analyzed the cause came up with four different aspects： 1. The patient provided erroneous information. 2. The staff lacked a sense of responsibility. 3. The health insurance card contained errors. 4. The system was faulty. After implementing countermeasure to the problem above the defects of the 3530 medical record from September to October were compared with the ones from May to June. The defect rate dropped from 12.9% to 2%. The difference was significant （P 〈0. 01 ）. Conclusions By strengthening communication with patients, providing user-friendly service, improving relevant services, strengthening the staff is responsibility sense, the hospital can raise the quality of medical records and services.

关 键 词：病案首页 基本信息 常见问题 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]