1647份首次病程记录缺陷分析及对策  

Defect Analysis and Countermeasures of 1647 First Course of Medical Records

作　　者：孙欣燕 孙冬梅[1] 薛缪群[1] 孙蓉蓉[1] Sun Xinyan;Sun Dongmei;Xue Miuqun;Sun Rongrong(Department of Quality Control, Nanjing Drum Tower Hospital The Affiliated Hospital of Nanjing University Medical school, Nanjing 210008, Jiangsu Province, China)

机构地区：[1]南京大学医学院附属鼓楼医院质管办,江苏省南京市210008

出　　处：《中国病案》2019年第5期11-13,共3页Chinese Medical Record

基　　金：南京大学医院管理研究所课题研究项目(南京鼓楼医院医学发展医疗救助基金会资助项目)(NDYG2018019)

摘　　要：目的通过分析某院首次病程记录中存在的问题,寻求改进对策,进一步提高病案的内涵质量,保证医疗质量与安全。方法按照江苏省《病历书写基本规范》中对首次病程记录的要求,对2018月4月-2018年9月期间1647份某院内、外科出院病案中存在缺陷的首次病程进行描述性统计分析。结果 303份病案首次病程存在缺陷,占所有病案的18.40%,首次病程缺陷按类别分为8项,各项的缺陷问题共计321例,其中诊疗计划缺陷占40.81%,诊断依据缺陷占16.51%,病例特点缺陷占15.89%。结论病案首次病程存在一定的缺陷。应完善电子病历系统的质量管理,加强全院病历书写规范化培训和科室的环节质控,促进多部门共同协作,开展全方位、全过程的首次病程质量管理,以提高病案首次病程质量。Objectives To figure out improvement strategies, further enhance connotation quality of First Course of medical record and ensure the quality and safety of medical care through analyzing problems in the first course of medical record. Methods On the basis of the first course requirements in Jiangsu Province "Writing Standards for Medical Records", descriptive statistical analysis was used to analyze defects in the first course of 1647 medical records. Results There were 303 first courses existing problems, which accounted for 18.40% of checked medical records. All defects in the first course were divided into 8 items. There were 321 defect problems totally, including defects of diagnosis and treatment plan(40.81%), defects of diagnosis and treatment basis(16.51%), and defects of case characteristics(15.89%). Conclusions Multiple factors led to defects in the first course of medical records.Improve quality management of electronic medical record system, strengthen standardized training of medical record in hospital and link quality control in clinical departments, promote collaboration across multiple departments, and implement full range and whole progress quality management of the first course. These played significant roles in improving quality of the first course, and enhancing clinicians’ ability of clinical thinking and level of diagnosis and treatment.

关 键 词：首次病程记录 病案 质控 

分 类 号：R197.323[医药卫生—卫生事业管理]