基于乙级病历为基础的病历缺陷项目分析与对策  

Analysis and Countermeasures of Medical Record Defective Items Based on Grade B Medical Record

作　　者：郝晓丽[1] 陈文梅[1] 王西坤 于燕平[1] 荆友斌[1] 刘金旭[1] 许振东[1] 张建锐 HAO Xiao-li;CHEN Wen-mei;WANG Xi-kun;YU Yan-ping;JING You-bin;LIU Jin-xu;XU Zhen-dong;ZHANG Jian-rui(People's Hospital of Pingdu,Pingdu,Shandong Province,266700 China)

机构地区：[1]平度市人民医院

出　　处：《中国卫生产业》2019年第36期169-171,共3页China Health Industry

摘　　要：目的对乙级病历进行缺陷项目的分析与研究制定对策。方法随机抽取山东省3家三级医院2018年1—6月乙级病历140份,缺陷项目406项质控数据进行分析。结果乙级病历中涉及的缺陷项目80%主要集中于入院记录、病案首页、病程记录、缺检查检验报告单、首次病程记录、出院记录。结论乙级病历缺陷项目多集中于入院记录、病案首页、病程记录、缺少检查报告单、首次病程记录与出院记录,应针对上述项目采取有效措施,如培训与质量控制体系建设、质控数据系统与网络信息化、闭环式多方位的病历质控系统,提高病历质量。Objective To analyze and study the defect items of Grade B medical records and formulate countermeasures.Methods 140 samples of Grade B medical records from January to June 2018 in three tertiary hospitals in Shandong Province were randomly selected,and 406 quality control data of defect items were analyzed.Results 80%of the defect items involved in the Grade B medical records were mainly concentrated in the admission records,the first page of the medical records,the course records,the lack of inspection report,the first course records,and the discharge records.Conclusion Most of the Grade B medical record deficiencies are concentrated on admission records,medical records,medical records,lack of inspection reports,first medical records and discharge records.Effective measures such as training and quality control system construction and quality control data systems should be adopted for the above items.Improve the quality of medical records with network informationization and closed-loop multi-faceted medical record quality control system.

关 键 词：乙级病历 缺陷项目 对策 

分 类 号：R47[医药卫生—护理学]