妇产科病案首页主要诊断与主要手术不一致性原因分析  

The Analysis and Countermeasure of Inconsistence of Major Diagnosis and Major Operation in the Front Sheet of Gynecology-Obstetric Medical Records

作　　者：方良欣[1] 谢琼[1] 邓群娣[1] 

机构地区：[1]广东省妇幼保健院,广州市510010

出　　处：《中国病案》2015年第8期19-21,共3页Chinese Medical Record

摘　　要：目的探讨妇产科住院病案首页的主要诊断和主要手术不一致的原因,研究如何合理选择妇产科病案首页的主要诊断,使其与主要手术操作相一致。方法提取2014年妇产科15 652份出院病案,其中11 588份含有各种妇产科手术操作,了解主要诊断与主要手术操作的填写情况。结果 11 588份住院病案的主要诊断和主要手术操作符合率77.5%,8981份主要诊断与主要手术相匹配,1043份属于部分不一致,1564份属于完全不一致。1043份部分不符合的病例中,妇科所占比例82.55%;产科仅占比17.45%。而1564份完全不符合的病例中,产科所占比例83.63%;妇科占比16.37%。结论主要诊断选择需要根据患者疾病的临床诊疗过程和主要诊断选择原则等多方面因素综合判断,主要手术操作应与主要诊断相对应。Objective To explore the reason on inconsistence of major diagnosis and major operation on the front sheet of Medical Record. It aims to find out how to select major diagnosis for Obstetrics reasonably so that they can be matched together. Method 15 652 cases of gynecology-obstetric medical records in 2014 were selected as research objects, 11 588 cases including all types of obstetric operation. We try to investigate the general picture of major diagnosis and major operation consistence. Result Among 11 588 medical records, total coincidence rate of major diagnosis and major operation was 77.5%, 8981 cases were completely matching,1043 cases were partly matching,1564 cases were totally inconsistent. In 1043 cases, Gynecology（82.55%）, Obstetrics（17.45%）; however among 1564 cases, Obstetrics（83.63%）, Gynecology（16.37%）. Conclusion Multiple factors should be taken account when selecting major diagnosis. Major operation should be carefully judged by major diagnosis.

关 键 词：妇产科 病案首页 主要诊断 主要手术 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]