基于电子病历的病案首页填写质量分析  

Analysis of filling quality on the first page of medical records based on electronic medical records

作　　者：杨燕媚[1] YANG Yan-mei(Medical Records Archive Room,Huizhou Central People忆s Hospital,Guangdong Province,Huizhui 516000,China)

机构地区：[1]广东省惠州市中心人民医院病案统计室,广东惠州516000

出　　处：《中国当代医药》2018年第9期133-135,共3页China Modern Medicine

基　　金：广东省惠州市科技计划项目(20150809)

摘　　要：目的检查电子病案首页填写质量,分析缺陷原因并提出整改措施。方法从电子病历导出2017年1~3月出院的19 974份出院的病历首页,对导出首页的基本信息、诊断信息、手术信息和其他信息的填写质量情况逐项检查并归类分析。结果病案首页缺陷率为2.34%,缺陷主要集中基本信息(56.33%),住院信息、诊断信息、符合情况、手术信息缺陷分别占比:12.09%、14.08%、2.56%、14.94%。结论我院电子病案首页填写缺陷较多。Objective To review the filling quality of the first page of electronic medical records,and to analyze the reasons for defects and put forward corrective measures.Methods A total of 19 974 pieces of the first page of medical records of the patients who were discharged from January 2017 to March 2018 were retrieved from the electronic medical records.The filling quality of the basic information,diagnosis information,surgery information and other information in the first page were reviewed respectively and analyzed by classification.Results The defect rate of the first page of medical records was 2.34%.The defect mainly focused on the basic information(56.33%),and the defect rate of hospitalization information,diagnosis information,accordance and surgery information was 12.09%,14.08%,2.56%and 14.94%respectively.Conclusion The filling defects of the first page of electronic medical records in our hospital are more.

关 键 词：电子病案首页 首页填写 质量分析 

分 类 号：R319[医药卫生—基础医学]