52份新冠肺炎死亡病案首页手术操作填写与编码实践  

Practice of Filling in and Coding of the Front Pages of the Medical Records of 52 Deceased Patients Infected with COVID-19

作　　者：彭君[1] 占云 潘振宇[1] Peng Jun;Zhan Yun;Pan Zhenyu(Zhongnan Hospital of Wuhan University,Wuhan 430071,Hubei Province,China;不详)

机构地区：[1]武汉大学中南医院,湖北省武汉市430071

出　　处：《中国病案》2020年第11期30-32,共3页Chinese Medical Record

摘　　要：目的探讨新冠肺炎病案首页手术操作填写及编码,确保病案首页数据质量。方法选取某院2020年1月1日-2020年4月30日住院上报大疫情网的新冠肺炎病案952例。其中52例为死亡病案。逐份对死亡病案首页、手术操作记录、医嘱单进行手术操作核查统计,应用SPSS19.0分析年龄及性别分布,应用Excel2007对手术操作填写情况进行分析。结果死亡病例中老年人占比82%,明显高于感染病例的38%。死亡病例中男性的占比71%,明显高于感染病例的45%。手术填写率高,占比100%,操作填写率低,占比37.82%,忽略主要手术操作选择,未进行主要手术操作选择占比达88.46%。结论病案管理关口前移,统一标准,根据相关指南质控文件及时进行数据修正,是新冠肺炎数据质量的重要保证。Objectives To explore the filling and coding of surgical operations on the front pages of COVID-19 medical records to ensure the quality of data on the front pages.Methods From January 1 st to April 30 th,2020,there were 952 people in total who were infected with COVID-19 in a hospital,and among which 52 people had died.This study collected data on the front pages,the operations and procedures and the physician’s order sheets from medical records for 52 deceased patients,and used SPSS(version 19)for analysis of age distribution and gender differences.Results 82%of 52 deceased patients being the old,was obviously higher than 38%of 952 infected patients as well as 71%being the man,higher than 45%.The operations all were filled in,and the filling rate was 100%,however some the procedures were blank,and the rate was 37.82%,There was,in addition,88.46%ignore pick of the major operations or procedures.Conclusions Moving forward management of medical records,unified,and revising data in time according to relevant guideline were necessarily guarantees of quality for the data.

关 键 词：新冠肺炎 病案首页 手术操作 

分 类 号：R197.323[医药卫生—卫生事业管理]