医院缺陷病历住院病案首页的质量缺陷分析与改进措施  

Analysis of Quality Defects in the First Page of Hospital Medical Records and Improvement Measures

作　　者：曾雪梅 景宜馨[1] 陈彪光 陈梅芬 ZENG Xuemei;JING Yixin;CHEN Biaoguang;CHEN Meifen(Department of Medical Record Information,Shenzhen Overseas Chinese Town Hospital,Shenzhen,Guangdong Province,518000 China)

机构地区：[1]深圳华侨城医院病案信息科,广东深圳518000

出　　处：《中国卫生产业》2021年第5期29-31,共3页China Health Industry

摘　　要：目的通过检查医院住院病案首页的填写情况,分析住院病案首页存在的质量缺陷,并提出针对性改进措施,以提高医院住院病案首页的信息质量。方法根据《住院病案首页数据填写质量规范(暂行)》,改进措施前,选取该院2018年1-12月全部出院的患者病案,共4434份;改进措施后,选取该院2019年1-12月全部出院的患者病案,共4248份,对比改进措施前后患者病案首页的信息质量和填写满意度。结果改进措施前项目填写缺陷率、疾病编码选择缺陷率、疾病诊断名称缺陷率、主要诊断选择缺陷率、手术操作编码选择缺陷率等均高于改进措施后,差异有统计学意义(P<0.05),改进措施前后,入院病情选择错误率、住院天数错误率和血型填写错误率等对比差异无统计学意义(P>0.05);改进措施前住院病案首页填写满意率低于改进措施后,差异有统计学意义(P<0.05)。结论医院通过完善病案首页管理流程、加强临床医师培训、建立疾病诊断数据库和手术操作数据库等改进措施,可有效提升了住院病案首页的信息质量,提高医务人员对病案首页填写的满意度。Objective By checking the filling of the first page of the hospital inpatient medical record,analyze the quality defects of the first page of the inpatient medical record,and propose targeted improvement measures to improve the information quality of the first page of the hospital inpatient medical record.Methods According to the"Quality Standards for Data Filling in the First Page of Inpatient Medical Records(Interim)",before the improvement measures,4434 medical records of all patients discharged from the hospital from January to December 2018 were selected;after the improvement measures,a total of 4248 medical records of all patients discharged from the hospital from January to December 2019 were selected,and the information quality and satisfaction degree of the patient's medical record first page before and after the improvement measures were compared.Results Before the improvement measures,the defect rate of filling in items,the defect rate of disease code selection,the defect rate of disease diagnosis name,the defect rate of main diagnosis selection,the defect rate of surgical operation code selection,etc.were all higher than after the improvement measures,the difference was statistically significant(P<0.05),before and after the improvement measures,there was no statistically significant difference in the error rate of admission condition selection,the error rate of hospitalization days,and the error rate of blood type filling(P>0.05);the satisfaction rate of filling in the first page of the hospitalization medical record before the improvement measures was lower than that after the improvement measures,the difference was statistically significant(P<0.05).Conclusion By improving the management process of medical record homepage,strengthening clinician training,establishing disease diagnosis database and surgical operation database,the hospital can effectively improve the information quality of inpatient medical record homepage and increase the satisfaction of medical staff with filling in medical record ho

关 键 词：住院病案 首页 缺陷病历 质量缺陷 改进措施 

分 类 号：R19[医药卫生—卫生事业管理]