病案首页填写中医院感染类医院获得性问题的质量分析  

Quality analysis of hospital-acquired problems with nosocomial infection in the first page of medical records

作　　者：冯晓莉[1] FENG Xiaoli(Hangzhou First People’s Hospital,Hangzhou 310006,China)

机构地区：[1]杭州市第一人民医院,浙江杭州310006

出　　处：《现代医院》2022年第5期714-717,共4页Modern Hospitals

基　　金：浙江省医学会临床科研资金项目(2016ZYC-A38)。

摘　　要：为评价病案首页中医院感染类获得性问题的填写情况,将病案系统中采集的医院感染类获得性问题与院感监测系统数据对比校验,发现病案首页中医院感染类获得性问题填写情况不容乐观,存在医院感染诊断遗漏、医院感染情况选择错误、医院感染诊断编码不准确等问题。通过分析这些问题存在的原因,提出需要加强医院感染数据的系统对接、提高临床医生对医院感染类诊断填写的正确认识和医院编码员业务能力建设等,进而提升病案首页中医院感染类获得性数据的准确性。In order to evaluate the filling of first page with infection acquisition form on the medical record homepage,the nosocomial infection acquisition form filling collected in the medical record system were compared with the data from the nosocomial infection monitoring system,and it was found that the nosocomial infection acquisition form filling on the medical record homepage had poor quality.There are problems such as omission of nosocomial infection diagnosis,wrong selection of nosocomial infection situation,and inaccurate diagnosis code of nosocomial infection.By analyzing the causes of these problems,it is proposed to strengthen the system connection of nosocomial infection data,improve clinicians’correct understanding of filling in nosocomial infection diagnosis and hospital disease diagnosis coders’professionalism.This will improve the accuracy of the data on nosocomial infections from the medical record home page.

关 键 词：医院感染 获得性问题 病案首页 

分 类 号：R197.323[医药卫生—卫生事业管理]