髋关节置换手术记录的缺陷分析  

Analysis of Defects in Hip Replacement Records

作　　者：张峰[1] 张磊[1] 侯大伟[1] 王琪 姚立帅 孙立晨 Zhang Feng;Zhang Lei;Hou Dawei;Wang Qi;Yao Lishuai;Sun Lichen(People's Hospital of Qingxian,Qingxian 062650,Hebei Province,China)

机构地区：[1]青县人民医院,河北省青县062650

出　　处：《中国病案》2020年第4期18-21,共4页Chinese Medical Record

摘　　要：目的通过对髋关节置换手术记录的缺陷进行分析,提高书写质量及手术安全管理。方法自某院病案管理系统调取2019年1月至12月期间行髋关节置换手术的62例病例,按照《河北省病历书写规范(2013年版)》《临床技术操作规范--骨科学分册》相关要求对手术记录进行专项检查。结果 62例髋关节置换手术记录中缺陷病例48例,占比77.42%,其中手术记录中未记录支撑轴面类型25例次,发生率最高,占比为21.37%,其次为手术经过记录不详细21例次,占比17.95%,手术名称不准确19例次,占比为16.24%,手术医师与麻醉记录不一致15例次,未记录术中输液量15例次,分别占比为12.82%,术中出血/输血情况记录缺陷5例次,占比4.27%,术者未签字3例次,置入物条形码粘贴缺陷1例次。结论髋关节置换手术记录质量函待进一步提高,需要注重落实病案书写规范的相关标准要求,并加强临床医师对临床技术操作规范、输血管理、ICD编码等相关知识的培训学习,以切实提高书写质量,促进手术患者的安全管理。Objective To improve the quality of writing and management of surgical safety by analyzing the defects in the records of hip replacement surgery.Methods 62 cases of hip replacement surgery which were from the medical record management system of a hospital,were retrieved from January to December 2019,and the surgical records were specially examined according to "Hebei Province Medical Record Writing Specification(2013 Edition)" and "Clinical Technical Operation Specification-Orthopedics Volume".Results There were 48 cases of defect in 62 hip replacement surgery records,accounting for 77.42%,of which 25 cases were unrecorded axial surface type accounting for 21.37%,with the highest incidence,followed by 21 cases of lacking details in the operation records,accounting for 17.95%.Cases that the name of operation was inaccurate occurred 19 times,accounting for 16.42%,Thus cases of inconsistency between the surgeon and the anesthesia record happened 15 times,which is the same as the number of cases that intraoperative infusion volume were not recorded,accounting for 12.82%.Defects in the records of intraoperative bleeding/transfusion occurred 5 times,accounting for 4.27%,defects that operators were not signed in the surgical records occurred 3 times and defects of placement barcode paste happened 1 time.Conclusion The quality of the operation records of hip replacement surgery needs to be further improved.It is necessary to pay attention to the implementation of relevant standards and requirements for the writing of medical records,and to strengthen the training of clinicians on clinical technical practices,blood transfusion management,ICD coding and other related knowledge,so that the quality of writing can be improved and the safety management of surgical patients can be promoted.

关 键 词：髋关节置换 手术记录 缺陷 分析 

分 类 号：R197.323[医药卫生—卫生事业管理]