病案首页填写缺陷的Meta分析  

Correction of Error in Recorded Cover Sheet Systematically Review and Meta Analysis

作　　者：俞红[1] 帅海平[1] 

机构地区：[1]上海交通大学附属第六人民医院,上海市200233

出　　处：《中国卫生信息管理杂志》2017年第2期236-242,共7页Chinese Journal of Health Informatics and Management

基　　金：上海市卫生和计划生育委员会科研课题(项目编号:201540319)

摘　　要：目的探讨填写缺陷对病案首页的影响,进一步提高病案首页数据质量。方法检索中文CNKI、万方、维普数据库发表的有关基于"病案首页填写缺陷"文章,对填写缺陷的研究影响进行系统综述和Meta分析。结果入选中文文献136篇,填写缺陷包括主要病案首页基本信息、诊疗信息、住院过程信息、费用信息四个方面内涵。Meta分析结果显示:病案首页质量管理介入后,首页缺陷率呈显著下降。结论病案首页质控管理是病历质量控制管理的重要环节,本文通过病案首页填写缺陷的系统综述,为病案首页质量控制管理评价体系的建立提供科学客观的依据。Objective A literature review was carried out on the defect of the cover sheet of medical records and its effects, to further improve the quality of medical records. Methods The literatures about the fill or the defect in medical recorded cover sheet were retrieved from CNKI, WF, VIP network, a metaanalysis was conducted. Results 136 articles that relevant to fill defect of medical records and the effects of it were included in the literature review, including basic information, diagnosis and treatment information, inpatient process information, and medical expenditure. Outcome of the meta-analysis showed that defect rate decline significantly after the adoption of quality management of the cover sheet of medical records. Conclusion Quality management plays an important role in improving the quality of medical records. This paper has provide an scientific evidence to quality management of cover sheet of the medical records.

关 键 词：病案首页 填写缺陷 系统综述 META分析 

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