病案首页缺陷分析与提高填写质量举措  

Defect Analysis of Front Page of Medical Records and Measures to Improve Filling Quality

作　　者：徐曦霖 XU Xilin(Medical Record Room,Shanghai Jiaotong University Medical College Affiliated Tongren Hospital,Shanghai,200050)

机构地区：[1]上海交通大学医学院附属同仁医院病案室,上海200050

出　　处：《智慧健康》2022年第9期4-6,共3页Smart Healthcare

摘　　要：目的 质控病案首页填写,分析缺陷原因并提出整改措施。方法 查阅2017年上半年我院病案首页缺陷病案数据,对病案首页相关信息的质量进行检查并对缺陷首页实施归纳分析并予以落实整改。结果 根据分析得出病案首页问题存在的影响因素包括信息化监测不到位、临床医师存在认识不足、管理人员业务素养不高,培训力度不够以及管理措施不到位等,提出了对临床医师加强病案首页的规范性书写培训。结论 提升病案管理人员的业务素养,加强信息化力度,最终提高病案首页质量。Objective To control quality of front page of medical records,analyze causes of defects and put forward rectification measures.Methods The paper consulted data of defective medical records on front page of medical records in our hospital at first half of 2017,checked quality of relevant information on front page of medical records,summarized,analyzed and rectified defective front pages.Results According to the analysis,influencing factors of front page problems of medical records include inadequate information monitoring,insufficient understanding of clinicians,low professional quality of managers,insufficient training and inadequate management measures.The paper put forward clinicians should strengthen standardized writing training of front page of medical records.Conclusion It is necessary to improve professional quality of medical record managers,strengthen informatization,and improve quality of front page of medical records finally.

关 键 词：病案首页 缺陷分析 落实整改 持续性改进 

分 类 号：R197.323[医药卫生—卫生事业管理]