某二级综合医院住院病案首页填报质量缺陷分析  

Quality Defects Analysis of the Front Page of Medical Records in a Secondary General Hospital

作　　者：杨华 贾惠莉 张娟 肖明 Yang Hua;Jia Huili;Zhang Juan;Xiao Ming(Changji Hui Autonomous Prefecture People's Hospital,Changji 831100,Xinjiang Uygur Autonomous Region,China;不详)

机构地区：[1]昌吉回族自治州人民医院,新疆维吾尔自治区昌吉市831100

出　　处：《中国病案》2021年第3期27-29,共3页Chinese Medical Record

基　　金：新疆昌吉州科学研究与技术开发计划项目(2019S01-03)。

摘　　要：目的分析住院病案首页填报质量缺陷并提出整改建议,为后期二级公立医院绩效考核做好准备工作。方法按照10%随机抽取2019年1月1日-2019年12月31日出院归档病案,按相关规范对住院病案首页逐项质控并将缺陷归类分析。结果随机抽取质控住院病案首页1283份,填报完整率为7.24%,其中患者信息填报完整率较低为8.49%,缺陷以项目漏填(75.44%)和填报不规范(40.91%)为主;住院信息填报完整率为89.16%,主要缺陷为逻辑错误(11.14%)、项目漏填(10.52%);诊疗信息填报完整率为92.36%,缺陷依次为其他诊断漏填占(16.52%)、主要诊断错误(9.27%)、入院病情选择错误(6.31%)。结论住院病案首页填报质量有待亟需提升和完善;医院通过强化病案首页填报培训、完善奖惩制度、加强病案质控和绩效考核、提高信息系统监测等措施可提高住院病案首页质量。Objectives To analyze the quality defects reported on the front page of inpatient medical records and put forward suggestions for rectification,so as to make a good foundation for the performance assessment of secondary public hospitals.Methods The medical records were randomly selected at 10%from January 1st,2019 to December 31st,2019,and the front page of inpatient medical records were qualitatively controlled and analyzed according to relevant regulations.Results The front page of the quality control inpatient medical records was randomly selected,and the completion rate was 7.24%,among which the completion rate of patient information was lower(8.49%).The defects were mainly missing items(75.44%)and non-standard reporting(40.91%).The completion rate of inpatient information was 89.16%,and the main defects were logical errors(11.14%)and missing items(10.52%).The completion rate of diagnosis and treatment information was 92.36%,followed by other missing diagnoses(16.52%),major diagnostic errors(9.27%)and admission condition selection errors(6.31%).Conclusions The filling quality of the front page of inpatient medical records needed to be improved and improved.The hospital could improve the quality of the front page of inpatient medical records by strengthening the training of the front page of medical records,perfecting the reward and punishment system,strengthening the quality control and performance assessment of medical records,and improving the monitoring of information system.

关 键 词：住院病案首页 质量 缺陷 分析 

分 类 号：R197.323[医药卫生—卫生事业管理]