疝与腹壁外科病案首页填写缺陷分析及对策  

Analysis and Countermeasure of the defect of first page of the medical record of department of hernia and abdominal wall

作　　者：徐晓明[1] 张琴[1] 曹玉龙[1] 杨桂月[1] 刘素君[2] 

机构地区：[1]首都医科大学附属北京朝阳医院西区病案统计科,北京100043 [2]首都医科大学附属北京朝阳医院疝与腹壁外科,北京100043

出　　处：《中华疝和腹壁外科杂志（电子版）》2016年第4期290-292,共3页Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition)

摘　　要：目的分析疝与腹壁外科病案首页填写缺陷,提出改进措施,以进一步提高该科病案首页的填写质量。方法抽取首都医科大学附属北京朝阳医院京西院区2015年疝与腹壁外科终末病案2 306份,对质控后发现的首页缺陷项进行汇总分析。结果 2015年4至12月该科终末病案2 306份中,首页缺项、错项、填写及书写不规范共计1 725例,其中包括基本信息189例,医疗信息1 536例。结论重视疝与腹壁外科病案首页信息的填写,加强医师培训,建立检查机制,以进一步提升该科病案首页信息填写质量。Objective Analysis of first page defects on medical records from hernia and abdominal wall department, put froward improvement measures to further improve the quality of the medical record first page filling. Methods A total of 2 306 medical records in 2015 of hernia and abdominal surgery were collected, and the defect items were collected and analyzed. Results Of the 2 306 final medical records from April 2015 to December 2016, a total of l 725 cases had missing or wrong data, nonstandard writing and or filling, including 189 cases in basic information, 1 536 cases in medical information. Conclusion Importance should be attached to the information of the first page on medical record of hernia and abdominal wall diseases. It is recommended to strengthen the doctors training and establish the inspection mechanism, so as to further improve the quality of the medical record.

关 键 词：病案管理 质量改进 缺陷 整改对策 

分 类 号：R197.323[医药卫生—卫生事业管理]