某院错位病案原因分析和对策探讨  

REASON ANALYSIS OF DISLOCATION MEDICAL RECORDS AND RELEVANT COUNTERMEASURES

作　　者：陈钟涛[1] 

机构地区：[1]中山市陈星海医院,广东中山528415

出　　处：《现代医院》2015年第6期141-142,144,共3页Modern Hospitals

基　　金：中山市卫生局新技术新项目(编号:2013T010)

摘　　要：目的对错位病案发生原因进行分析，不断整改病案管理整个环节，探讨降低错位病案发生率的对策。方法收集某院2010年1月～2014年1月无意中或需要提供病案时发现的错位病案177份，对发生原因进行整理分析，采用电子签名检测系统、色标、条码管理病案。结果177份病案中142份因看错号码放错位置；15份因再次住院归档时放错病案袋；20份因两本病案叠在一起归档放错位置。在实施整改后，2010-2013年病案错位率分别为0．44％、0．27％、0．11％、0．01％。2010年1月-2014年1月共有病案89108例，发现错位病案177份，错位病案发生率为O．20％。2010—2013年病案错位率呈逐年下降趋势，各年度间比较差异有统计学意义（P〈0．01）。结论导致病案错位的原因很多，只有在病案管理过程中不断的发现问题，采取有效的管理方法解决问题，才能达到病案管理零差错，最大效率地发挥病案作用。Objective Though conducting reason analysis on dislocation medical records, continue to rectifi- cation in each link of medical records management, study how to reduce the incidence of dislocation medical records. Methods 177 dislocation medical records were collected in our work in our hospital from 2010 January to 2014 Jan- uary. We take electronic signature detection system, color, and barcode to manage medical records. Results Among dislocation 177 medical records, there were 142 dislocation cases misplaced because of wrong numbers; 15 dislocation cases misplaced because of filing into the wrong case bags while rehospitalized; 20 dislocation cases misplaced because of the two adjacent cases stacked together. After the rectification of each link in medical records archiving, the disloca- tion rate from year 2010 to 2013 were 0.44% ,0.27% ,0.11% and 0.01%. From January 2010 to January 2014, 177 misplaced medical records were found in a total of 89,108 medical records cases. The medical records dislocation rate was 0.20%. Medical records dislocation rate showed a declining trend from 2010 to 2013, and the dislocation rate of medical records decreased year by year （p 〈 0.01 ）. Conclusion There are many reasons leading to dislocation medical records. Only by summing up experience constantly, finding the problem and adopt effective management method to solve the oroblem, we could achieve zero error and a maximum efficiency of medical records.

关 键 词：错位病案 原因分析 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]