病案首页信息填写缺陷分析与建议  

The Analysis and Countermeasure of the Quality Defects in the Front Page of Medical Record

作　　者：许慧娜[1] 卢介珍[1] 吴玉连[1] 卢红[1] 张增文 XU Huina;LU Jiezhen;WU Yulian;LU Hong;ZHANG Zengwen(Medicalrecord Department,First Affiliated Hospital of Xiamen University,Xiamen Fujian 361000,China)

机构地区：[1]厦门大学附属第一医院病案室,福建厦门361000

出　　处：《中国卫生标准管理》2018年第22期21-23,共3页China Health Standard Management

摘　　要：目的了解全市二级及以上医院出院病案首页填写质量,针对发现的问题提出对策与建议。方法组织全市病案管理专家,抽查某市二级及以上医院2017年10月出院病案共290份进行病案首页专项检查,统计分析缺陷问题,并进行原因分析。结果病案首页缺陷共计发生频次458次,其中患者基本信息缺陷211频次,缺陷率46.07%;住院过程信息缺损缺损78频次,缺陷率17.03%;诊断信息缺陷169频次,缺陷率36.90%。结论加强对医生的培训,提升病案工作人员专业水平,强化病案信息系统建设,建立完善的质控体系等,有助于提高病案首页填写质量。Objective To understand the quality defects existing in the front pages of medical records in secondary hospital and above,and to put forward some measures for improvement.Methods The front pages of 290 medical records in October 2017 from secondary hospital and above were examined by case management experts,and the defects were analyzed to seek countermeasures.Results Total number of defects on the front page of the medical record was 458,the frequency of patients basic information defects was 211,the defeat rate was 46.07%;the frequency of hospitalized process defects was 78,the defeat rate was 17.03%;the frequency of clinical diagnostic information defeats was 169,the defeat rate was 36.90%.Conclusion Strengthening doctor training,improving the professional level of the medical record staff,strengthening the construction of the medical record information system,and establishing a perfect quality system will help to improve the quality of the front page of the medical record.

关 键 词：病案首页 填写缺陷 培训 编码水平 信息化建设 质控系统 

分 类 号：R197[医药卫生—卫生事业管理]