康复医学科病案首页缺陷分析及干预策略  

The defect analysis and intervention strategy of medical record in rehabilitation medicine department

作　　者：刘丽[1] 王森[1] 胡丹[1] LIU Li;WANG Sen;HU Dan(Yangzhi Rehabilitation Hospital Affiliated to Tongji University,Shanghai 201619,China)

机构地区：[1]同济大学附属养志康复医院,上海201619

出　　处：《现代医院》2022年第4期573-575,共3页Modern Hospitals

摘　　要：目的分析某重点康复专科医院康复医学科住院病案首页的缺陷,提出干预策略,不断提升病案首页的填写质量。方法随机抽取某重点康复专科医院康复医学科2020年1月1日—2021年12月31日1655份住院病案,根据病案专业知识与病历质控标准,对病案首页进行复查,统计缺陷率,分析缺陷原因。结果1655份住院病案首页的填写缺陷率为9.55%,缺陷构成比为主要诊断选择错误3.50%、编码遗漏1.93%、未使用合并编码1.69%、入院病情选择错误1.39%、笼统编码0.66%、离院方式选择错误0.36%。结论康复医学科住院病案首页质量有待亟需完善和提高,只有多学科多团队协作学习,多部门多环节加强管控,才能不断降低康复医学科住院病案首页的缺陷率,逐步提升病案首页的数据质量。Objective To analyze the defects of the first page of inpatient medical records in rehabilitation medicine department of a key rehabilitation hospital,and to put forward intervention strategies to improve the quality of filling in first page.Methods A total of 1655 inpatients from January 1,2020 to December 31,2021 in a key rehabilitation hospital were randomly selected.According to medical record professional knowledge and medical record quality control standard,the first page of medical record was rechecked,the defect rate was counted and the reason of defect was analyzed.Results The defect rate of the first page of 1655 inpatient medical records was 9.55%.The component ratio of errors in the main diagnosis was 3.50%,code omission 1.93%,combined codes not used 1.69%,disease errors in admission 1.39%,general codes 0.66%,and discharge errors 0.36%.Conclusion The quality of the first page of inpatient medical records in rehabilitation medicine department needs to be improved urgently.Only by multi-disciplinary and multi-team cooperation learning and multi-department and multi-link strengthening control,can we continuously reduce the defect rate of the front page of the inpatient medical record in rehabilitation medical department,and gradually improve the data quality.

关 键 词：康复医学科 病案首页 缺陷分析 干预策略 

分 类 号：R197.323.1[医药卫生—卫生事业管理]