某三级公立综合医院住院病案首页缺陷分析  

Analysis on the defects of the first page of inpatient medical records in a tertiary general hospital

作　　者：杜惠丽[1] 路伟 梁泽峰[1] DU Huili;LU Wei;LIANG Zefeng(The Second Hospital of Shanxi Medical University,Taiyuan 030001,China;Hainan Medical College,Haikou 571199,China)

机构地区：[1]山西医科大学第二医院,山西太原030001 [2]海南医学院,海南海口571199

出　　处：《临床医药实践》2022年第8期637-640,共4页Proceeding of Clinical Medicine

摘　　要：目的:分析DRGs/DIP分组下住院病案首页的缺陷及原因,改善医院质量管理与控制指标(以下简称质控)工作,提高住院病案首页质量。方法:由专职人员通过医院信息系统导出全院2019年—2020年归档病案131822份,回顾性分析其中的缺陷住院病案首页18046份,并进行缺陷归类和统计分析。结果:首页缺陷主要有首页漏签字、缺项和漏填错填三类问题,其中,首页缺项问题最明显。医师职称越高填写质量越高,女性医师填写质量高于男性。2020年总体缺陷率低于2019年,差异有统计学意义(P<0.05)。2019年与2020年非手术类科室缺陷率均低于手术类科室,差异有统计学意义(P<0.05)。结论:某三级公立综合医院在首页漏填错填问题上应予以重视,可通过进一步加强质控及绩效考核,对质控工作进行及时调整,加强培训及整改反馈等工作,降低病案首页缺陷的发生率。Objective:To analyze the defects and causes of the first page of inpatient medical records under DRGs/DIP grouping,and improve the quality control of the hospital and the quality of the first page of inpatient medical records.Methods:Through the hospital information system,the full-time staff exported 131822 medical records filed in the whole hospital from 2019 to 2020,retrospectively analyzed 18046 defective inpatient medical records on the first page,and classified and statistically analyzed the defects.Results:Home page defects mainly include missing signature,missing items and missing and wrong filling on the home page,among which the missing and wrong filling on the home page is the most obvious.The higher the doctor's title,the higher the filling quality,and the filling quality of female doctors is higher than that of male doctors.The overall defect rate in 2020 is lower than that in 2019(P<0.05),and the defect rate in non-surgical departments in 2019 and 2020 is lower than that in surgical departments(P<0.05).Conclusion:A three-level public general hospital should pay attention to the problem of missing and wrong filling on the front page.The incidence of defects on the front page of medical records can be reduced by further strengthening quality control and performance assessment,timely adjusting quality control,enhancing training and rectification feedback.

关 键 词：综合医院 病案首页 缺陷分析 

分 类 号：R197.3[医药卫生—卫生事业管理]