死亡医学证明书致死疾病填写与病案一致性的分析  

Medical Record Check-Up Consistency Analysis of the Death Medical Certificate

作　　者：谈敦芳[1] 张奇[1] 黄利琼 胡英[1] 张松建[1] Tan Dunfang;Zhang Qi;HuangLiqiong;Hu Ying;Zhang Songjian(Disease Control and Prevention Center of Shunyi District,Beijing 101300,China)

机构地区：[1]北京市顺义区疾病预防控制中心

出　　处：《中国病案》2019年第12期22-25,共4页Chinese Medical Record

摘　　要：目的评价北京市某区医疗机构内死亡病案与医学证明书致死疾病的一致性,以及由此判断根本死因的准确性,旨在提高医疗机构内死亡报告质量。方法通过查阅区域内4家二级及以上医疗机构2018年1月-2018年12月报告的200例死亡病例的病案,复核死亡证明书致死疾病填写的一致性以及由此推导出来的根本死因的准确性。结果 200例死亡病例的死因链与病案的复核符合率为78.50%;二级医疗机构一致率低于三级医疗机构,X^2=248,P<0.001;24.00%根本死因被填报错误,31.50%根本死因判断不准确。结论辖区医疗机构内死亡病例死因报告的准确性较高,但还应加强临床医师关于依据病案填写死亡证明书致死疾病即死因链的培训,以及死因报告专职人员关于根本死因判断原则及编码的培训。Objective To evaluate consistency of the fatal diseases between medical record check-up and the death medical certificatein Some District of Beijing, in order to improve the quality of death reports.Methods Referring to the medical records of 200 death casesby four secondary hospitals in 2018, reviewing the consistency about the fatal diseases between medical records and the death medical certificate.Results The consistent rate of fatal diseases was 78.50% in 200 cases.The consistency rate of secondary hospitals was lower than that of tertiary hospitals(chi-square =248,P≤0.001).The root cause of death was incorrectly reported by 24.00% and was not accurate reported by 31.50%. Conclusion The accuracy of death report hospital is higher, butthe training of clinicians on how to fill in the death certificate according to the medical record, and the training of the International Classification of Diseases in particular, the principle on the root cause of death.

关 键 词：死亡医学证明书 病案复核 根本死因 

分 类 号：R197.323[医药卫生—卫生事业管理]