17930份终末病案书写缺陷分析  

Analysis of writing defects in 17,930 terminal medical records

作　　者：刘晶[1] Liu Jing(Department of Case Management,Outpatient Department,First Medical Center,PLA General Hospital,Beijing,100853,China)

机构地区：[1]解放军总医院第一医学中心门诊部病案管理科,北京市100853

出　　处：《中国病案》2023年第1期14-17,共4页Chinese Medical Record

摘　　要：目的 对终末病案书写质量进行检查,分析病案书写缺陷构成,探索缺陷病案原因,提出针对性解决对策。方法 在医院病案质量控制系统的终末病案检查子系统中,调取时间区间为2021年1月1日-2021年6月30日终末病案,每月按出院科室终末病案的20%-30%进行随机抽取,合计检查17 930份,按照科室、问题类型、检查问题清单三种方式进行统计,信息导入Excel表,对检查情况及缺陷情况进行分析。结果 17 930份终末病案,合格病案17 773份,不合格病案157份,合格率99.12%。主要缺陷情况有出院记录缺陷(31.42%)、入院记录缺陷(24.26%)、授权委托书和知情同意书缺陷(18.29%)、病程记录缺陷(17.27%)、手术及其相关记录问题缺陷(8.76%)。结论 通过加强医师病案书写规范化培训、优化病案系统、强化法律意识、建立奖惩机制等措施,可以提高医师对病案书写的重视,降低病案缺陷率,提高病案质量,提升医院医疗质量和管理水平。Objectives This study aims to check the writing quality of terminal medical records, analyze the composition of defects in medical record writing, explore the causes of defective medical records, and propose targeted solutions.Methods The terminal medical records from January 1, 2021 to June 30, 2021 were retrieved from the terminal medical record inspection subsystem of the hospital medical record quality control system.20%-30% of the terminal medical records of the discharged departments were randomly selected every month, and a total of 17,930 cases were examined. Statistics were carried out in three ways: department, problem type, and inspection problem list, and the information was imported into an Excel sheet to analyze the inspection situation and defects.Results 17,930 terminal medical records included17 773 qualified medical records and 157unqualified medical records, with a pass rate of 99.12%.The main deficiencies were discharge record deficiencies(31.42%), admission record deficiencies(24.26%), power of attorney and informed consent deficiencies(18.29%), disease course record deficiencies(17.27%), and surgery and related record deficiencies(8.76%).Conclusions By strengthening the standardized training of physicians’ medical record writing, optimizing the medical record system, strengthening legal awareness, and establishing a reward and punishment mechanism, it is possible to increase physicians’ attention to medical record writing, reduce the defect rate of medical records,improve the quality of medical records, and improve the quality of hospital medical care and management.

关 键 词：终末病案 书写 病案质量 缺陷分析 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]