某院住院病案首页诊断信息缺陷分析  

Analysis on the Defects of Diagnostic Information on the Home Page of Medical Record

作　　者：雷哲 严红艳 刘江伟[3] Lei Zhe;Yan Hongyan;Liu Jiangwei(Basic Medicine College of Medical University of PLA Air Force,Xi'an 710032,Shanxi Province,China;Key Laboratory of Special Environmental Medicine of Xinjiang Military Region General Hospital,Urumqi 830003,Xinjiang,China)

机构地区：[1]空军军医大学基础医学院,陕西省西安市710032 [2]临潼康复疗养中心,陕西省西安市710600 [3]新疆军区总医院新疆特殊环境医学重点实验室,新疆维吾尔自治区乌鲁木齐市830000

出　　处：《中国病案》2019年第10期21-23,共3页Chinese Medical Record

基　　金：军队临床高新技术重大项目(2010gxjs016)

摘　　要：目的通过对"军卫一号"数据库中诊断信息质量检查,对存在的问题进行归纳分析,为规范诊断信息、提高诊断质量提供参考。方法对军队某三级医院2018年1月1日-2018年12月31日出院的36136份归档病案进行数据库统计,调查缺陷诊断,分析缺陷原因,总结存在的问题类型及频次。结果在15200条诊断信息缺陷中,主要疾病诊断缺陷3204频次(21.08%)、主要手术操作缺陷3021频次(19.88%)、其他手术操作缺陷2154频次(14.17%)、其他疾病诊断缺陷1587频次(10.44%),这四项缺陷发生频次占总发生频次的65.67%。结论诊断缺陷率较高的是主要诊断和主要手术,其他诊断缺陷问题也不容忽视。病案管理人员和临床医师要重视提高书写质量,确保疾病诊断的准确性和真实性,提高病案首页诊断信息质量。Objective To summarize and analyze the existing problems by checking the quality of diagnostic information in No.1 Military Medical Database,so as to provide references for standardizing diagnostic information,reducing diagnostic defects and improving diagnostic quality.Methods A total of 36,136 archived medical records discharged from a third-class a hospital of the PLA from January 1,2018 to December 31,2018 were statistically analyzed,defect diagnosis was investigated,defect causes were analyzed,and existing problem types and frequencies were summarized.Results Among 15 200 diagnostic information defects,3 204(21.08%) of the major diseases,3 021(19.88%) of the major surgical operation defects,2 154(14.17%) of the other surgical operation defects,and 1 587(10.44%) of the other diseases were diagnosed.These four defects accounted for 65.67% of the total occurrence frequency.Conclusion The rate of major diagnosis and surgical defects is high,and other diagnostic defects should not be neglected.Medical record managers and clinicians should pay attention to improving the quality of writing,ensuring the accuracy and authenticity of disease diagnosis,and improving the quality of diagnosis information on the front page of medical records.

关 键 词：病案首页 诊断信息 缺陷 对策 

分 类 号：TP3[自动化与计算机技术—计算机科学与技术]