病案首页质量监控分析  

Analysis of Quality Control of Medical Record Home

作　　者：张军军[1] 

机构地区：[1]江苏省江阴市人民医院病案科,江苏江阴214400

出　　处：《中国卫生标准管理》2016年第16期27-28,共2页China Health Standard Management

摘　　要：目的探讨病案首页质量监控方法。方法选取我院2015年信息系统监控的88 224份病案首页信息,以Excel形式展开分类统计,分析病案填写的错误率。结果 88 224份病案首页信息中,信息错误填写共计5 790份,错误率为6.6%。其中,患者基本信息不完善的构成比最高,为27.2%,其次是出院诊断填写错误,临床路径误填漏填,疾病和手术操作编码不准确,血型误填,诊断符合情况错漏填等。结论完善患者基本信息是改善病案首页质量的必要前提,降低填写错误是改善病案首页质量的关键,提高责任心、加强训练、强化监察力度等措施是改善病案首页质量的主要任务。Objective To explore the technology and application of method of medical records quality control. Methods 2015 information monitoring system of 88 224 copies of the first page of the medical record information in our hospital were selected, in the form of Excel expansion statistical classification, the error rate of the medical records to fill were analyzed. Results 88 224 copies of the first page of the medical record information, and error information filled was 5 790, error rate was 6.6%. Among them, basic information of the patients was not perfect form was the highest, the rate was 27.2%, followed by discharge diagnosis fill in error, clinical pathway mistakenly fill or forgot fill, disease and technical operation code was not accurate, blood type mistakenly fill, diagnosis accord with wrong leakage fill etc. Conclusion To improve the patient＇s basic information is a necessary precondition for the first page of the medical record quality improvement, reduce fill in error is the key to improve the quality of medical record home, improve the sense of responsibility, strengthen training, strengthen supervision and other measures to improve the main task of the first page of the medical record quality.

关 键 词：病案 质量监控 方法 分析 

分 类 号：R197.323[医药卫生—卫生事业管理]