某三甲医院病案首页质量分析及改进措施  

Quality analysis and Improvement of Front Page of Medical Record in a Third Grade Class A Hospital

作　　者：崔妹娟 刘芳[1] Cui Meijuan;Liu Fang(The Third Hospital of Hebei Medical University, Shijiazhuang 050051, Hebei Province, China)

机构地区：[1]河北医科大学第三医院,石家庄市050051

出　　处：《中国病案》2017年第12期33-35,共3页Chinese Medical Record

基　　金：2017年河北省医学科学研究课题(20170650)

摘　　要：目的了解病案首页现况,采取相应的管理措施,提高病案首页质量。方法调查并分析了2016年7月1日-2016年12月31日的1400份病案首页在质控三个阶段的缺陷情况,结合多种病案首页质控方法,提出改进措施。结果 1400份病案首页在初步筛检时发现793份有缺陷,缺陷率为56.8%,在归档过程中发现462份有缺陷,缺陷率为32.9%,抽查已归档病案发现存在缺陷的有85份,缺陷率为6.1%。结论通过加强医务人员对病案重要性的认识、定期开展病案首页填写培训、加快电子病案信息平台建设以及提升病案医务人员的业务能力等措施,确保医疗信息的准确性和完整性。Objective To investigate the status of first page of medical records and improve the quality. Methods To survey and analyze the filling of first page of 1400 medical records in the three stages of quality controlfrom July 2016 to December 2016. And we propose improvement measures combined with a various of the quality control method for first page of medical records. Results We found that 793 cases（56.8%）were defective in the initial screening and 462 cases（32.9%） in the archiving process. There were 85（6.1%） cases of defective in the archived medical records.Conclusion We should improve the quality of first pages of medical records and ensure the accuracy and reliability of medical information by paying more attention to the medicalrecords,improving the skill for medical records,constructing of electronic medical record information platform and improving the operational capacity of the medical staff.

关 键 词：病案首页 缺陷 质量控制 改进 

分 类 号：R197.323[医药卫生—卫生事业管理]