专项整改前后住院死亡病案首页质量分析  

Quality Analysis of the First Page on Death Medical Records Before and After Special Rectification

作　　者：来丽琦 刘艳斌[1] Lai Liqi;LiuYanbin(People's Hospital of Beijing Daxing District,Beijing 102600,China)

机构地区：[1]北京市大兴区人民医院

出　　处：《中国病案》2019年第12期8-10,共3页Chinese Medical Record

基　　金：2018年北京市大兴区人民医院院级课题(4201855258)

摘　　要：目的通过住院病案首页专项整改工作探索住院死亡病案管理方法,分析存在问题及改进措施,提升死亡病案的书写质量。方法采用回顾性调查方法,选取整改专项工作前2017年1月-2017年12月和整改专项工作后2018年1月-2018年12月死亡病案进行对照,按照《住院病案首页数据填写质量规范(暂行)》的标准和"北京地区住院医疗服务绩效评价平台"数据进行分析。结果 2017年住院死亡病案首页主要诊断选错71次,其他诊断漏填54次,未填写呼吸机使用类型的缺陷有96次,当年缺陷构成比分别为24.07%、18.31%、32.54%;2018年主要诊断选择错误32次、其他诊断漏填31次、未填写呼吸机使用类型15次,当年缺陷构成比分别为35.96%、34.83%和16.85%。2017年缺陷量占2年总数的76.82%,专项工作开展后2018年缺陷占2年总数23.18%。结论通过开展专项工作,某医院住院死亡病案首页质量明显提升,优化提高了住院病案首页的编码质量,降低了缺陷例数,专项整改效果显著。Objective By carrying out special inspection on the first pageof medical records,the hospital explore the management methods of death medical records, analyze the existing problems and summarize the measures, in addition to improve the quality of writing death medical records.Methods A retrospective survey was conducted to compare all the death records in 2017 and after special inspection in 2018, and the records were analyzed according to the standard of "Quality Specification for Filling in Home Page Data of Inpatient Medical Records(interim) and "Beijing hospitalization medical service performance evaluation platform". Results In 2017, 71 major diagnostic errors and 54 other diagnostic errors were made as well as 96 cases of defects in the type of breathing machine were not written, the constituent ratios were 24.07%, 18.31% and 32.54% respectively. In 2018, 32 major diagnostic errors and 31 other diagnostic errors were made as well as 15 cases of defects in the type of breathing machine were not written, the constituent ratios were 35.96%、34.83% and 16.85% respectively. Defects accounted for 76.82% of the total in 2017 and 23.18% of the total in 2018. Conclusion Through the special inspection,the quality of the front page of death medical records has been significantly improved,the coding quality has been optimized, the number of defects has been reduced. The effect of special rectification is remarkable, and it has reference significance.

关 键 词：病案首页 专项整改工作 死亡病案 

分 类 号：R197.323[医药卫生—卫生事业管理]