120份死亡病案首页质量综合分析  

Comprehensive analysis of 120 front sheets of death medical records

作　　者：王晓成[1] 陈华 乔薪纳 王美玲 Wang Xiaocheng Chen Hua Qiao Xinna Wang Meiling(Department of Medical Record Management, Shanxi Provincial People＇s Hospital, Taiyuan 030012, China)

机构地区：[1]山西省人民医院病案统计室,太原030012 [2]山西医科大学汾阳学院

出　　处：《中国医院统计》2017年第4期250-253,共4页Chinese Journal of Hospital Statistics

摘　　要：目的针对死亡病案首页进行缺项及评分分析,以提高病案首页填写质量,加强质量控制。方法调取某院2016年1-12月120份死亡病案,采用国家卫生计生委发布的住院病案首页数据质量评分标准,进行病案首页统计分析,并比较内外科系统病案首页间的差异性。结果死亡病案首页缺项问题较多;整体完整率为90.00%;总体病案首页评分为(90.68±4.71)分;评分等级为优和良的病案分别占5.8%和51.7%;内外科间评分等级无差异。结论病案首页质量不佳,应采取各种方法加强医务人员培训、提高对病案首页填写知识的认识,进而促进病案首页质量提升,确保医疗信息质量与医疗安全。Objective To analyze missing items and scoring of front sheets of death medical records , in order to im- prove the quality of medical records and strengthen quality control. Methods One hundred and twenty front sheets of death medical records from January to December in 2016 were checked according to the quality criteria of Hospital medical record home page data published by the National Health and Family Planning Commission, and the differences of front sheets between the in- ternal medicine and surgery were compared. Results Many missing items of front Sheet of death medical record home page were found. The whole complete rate was 90.00%. General score was 90.68＋4.71 points. Medical records rated as best and good ac- counted for 5.8% and 51.7% respectively. The rating had no difference between internal medicine and surgery. Conclusion The quality of front sheets of death medical records was poor. Various methods should be taken to strengthen staff training, im- prove the understanding of the knowledge of the medical record home page, and promote quality improvement, so as to ensure the quality of medical information and medical safety.

关 键 词：死亡病案 病案首页 质量管理 

分 类 号：R197.323[医药卫生—卫生事业管理]