北京市中医类眼科专科医院病案质量调查分析  

Investigation and analysis on the quality of medical records in Beijing Traditional Chinese Medicine Ophthalmic Hospital

作　　者：孙红霞 郭晓勤[1] 夏秋芳[1] 杨剑英[1] 李欣[1] 周雅琪[1] SUN Hongxia;GUO Xiaoqin;XIA Qiufang;YANG Jiany-ing;LI Xin;ZHOU Yaqi(Eye Hospital,China Academy of Chinese Medical Sciences,Beijing,100040,China)

机构地区：[1]中国中医科学院眼科医院,北京100040

出　　处：《中国中医眼科杂志》2022年第11期921-924,共4页China Journal of Chinese Ophthalmology

基　　金：中国中医科学院科技创新工程(CI2021A05405)。

摘　　要：目的 调查研究北京市中医类眼科专科医院的病案质量,为眼科临床研究提供更准确更严谨的基础材料。方法 通过回顾性分析2020年10月—2021年9月北京市中医类眼科专科医院出院患者病案资料,统计其返修率、常见错误和各科室的返修率排序,并对病案进行评分和分级。结果 共纳入中医眼科专科医院1所,病案9,915份,涉及眼科8个亚科室,病种共261种。共返修2,139份,返修率为21.57%,二次返修共205份,二次返修率为9.58%。返修的错误条目中以首页“其他手术及操作”漏报或填写不规范最多。手术病案返修率高于非手术病案返修率,非手术病案二次返修率高于手术病案二次返修率。甲级病案9,421份,占比95.02%;乙级病案494份,占比4.98%。结论 本次纳入的北京市中医类眼科专科医院的病案质量相对较好,甲级病案占比较高,但返修率稍高,病案首页填报质量有待提高,尤其是其他手术及操作的完整填报和手术相关质量的控制仍需改进。OBJECTIVE To investigate and study the quality of medical records in Beijing Traditional Chinese Medicine(TCM) Ophthalmic Hospitals, so as to provide more accurate and rigorous basic materials for clinical analysis and research of ophthalmology.METHODS Through retrospective analysis of the medical records of discharged patients from Beijing TCM Ophthalmic Hospitals from October 2020 to September 2021, the repair rate, common errors and the repair rate ranking of each department were counted, and the medical records were scored and graded.RESULTSA total of 9,915 medical records were included in one hospital, involving eight subdepartments of ophthalmology and 261 kinds of diseases. A total of 2,139 copies were repaired,the repair rate was 21.57%.Meanwhile, 205 copies were repaired twice, the second repair rate was9.58%. Among the error items repaired, the "other surgeries and operations" on the home page were mostly omitted or filled in lacking standardization. The repair rate of surgical medical records was higher than that in non-surgical ones. However, the second repair rate of non-surgical mecical records was higher than that of surgical ones. There were 9, 421 grade A medical records,accounting for 95.02%, 494 grade B medical records, accounting for 4.98%.CONCLUSIONS The quality of medical records in Beijing TCM Ophthalmic Hospitals is good, with a relatively high proportion of grade A medical records. However, the repair rate is slightly higher, and the quality of the front pate needs to be improved,especially the complete filling of "other surgeries and operations" and the quality control related to surgeries.

关 键 词：病案质量 病案返修率 病案分级 

分 类 号：R276.7[医药卫生—中医五官科学]