烧伤科病案首页手术操作名称填写质量分析  

Quality Analysis on Operation Name in Front Sheet of Burn Surgical Medical Records

作　　者：倪俊[1] 许献荣[1] 顾海峰[1] 陈瑞彩[1] 

机构地区：[1]解放军第八五医院烧伤整形外科,上海市200052

出　　处：《中国病案》2015年第10期25-27,共3页Chinese Medical Record

摘　　要：目的分析烧伤科病案首页手术名称填写缺陷原因,探索提高质量方法。方法以病案首页填写规范和ICD-9-CM-3分类编码原则为标准,对某院烧伤科2012年1月至2014年12月病案随机检查100份,分析病案首页手术名称填写缺陷。结果共检查出缺陷病案24份,其中手术操作名称书写缺陷15份,主要手术操作选择错误6份,漏记手术操作名称3份。结论认识不足、知识缺乏、重视不够、质控不力是烧伤科病案首页手术操作名称填写存在缺陷原因。提高认识、加强培训、强化质控有助于提高病案首页质量。Objective To monitor the quality of operation name writing in front sheet of burn surgical medical records and analyze the methods to improve the quality. Methods 100 cases of discharged burn surgical medical records in our hospital from January 2012 to December 2014 were inspected randomly, and conducted retrospective analysis on the operation name in front of those medical records. Results 24 cases were found out defects in operation name. The defects involved in deficiencies of the operation name（15 cases）, wrong selection of principle operations name（6 cases）, and unrecorded operation procedure name（3 cases）. Conclusion The quality problems existing sheet of burn surgical medical records. Recognize the importance of ICD-9-CM-3 coding, master the principles of operation procedure classification and strengthen quality control could improve the quality of front sheet of burn surgical medical records.

关 键 词：烧伤 病案首页 手术操作名称 ICD-9-CM-3 

分 类 号：R197.323[医药卫生—卫生事业管理]