某三级公立医院耳鼻喉科病案首页填写质量分析  

Analysis of the quality of filling in the first page of the medical records of otolaryngology department of a tertiary public hospital

作　　者：王艳华[1] 代彦丽 张志鹏 段文锴[1] Wang Yan-hua;Dai Yan-li;Zhang Zhi-peng;Duan Wen-kai(Department of Medical Records,Luohe Central Hospital,Luohe 462000,China)

机构地区：[1]漯河市中心医院病案室,河南漯河462000

出　　处：《四川生理科学杂志》2024年第4期855-857,共3页Sichuan Journal of Physiological Sciences

摘　　要：目的:探讨某三级公立医院耳鼻喉科病案首页填写质量现况及其影响因素。方法:选取2018年1月至2022年12月某院耳鼻喉科1000份病案资料,评估病案质量,以病案质量是否合格分组,其中856份合格病历,纳入对照组;144份不合格病历,纳入观察组。比较两组临床资料,如性别、年龄、学历、职称、患者住院时间,采用Logistic回归分析病案质量影响因素。结果:本研究1000份病案资料,优级病案为856份,良57份,中42份,低31份,劣14份,缺陷率为14.4%(144/1000)。观察组年龄>50岁、副主任医师比例低于对照组,患者住院时间比例>10 d高于对照组(P<0.05)。年龄、职称、患者住院时间是病案质量的影响因素(P<0.05)。结论:医院病案填写质量仍有待提高,受年龄、职称、患者住院时间等影响。Objective:To investigate the status and influencing factors of filling quality of the first page of medical records in Otolaryngology department of a tertiary public hospital.Methods:1000 medical records from Otolaryngology department of a hospital from January 2018 to December 2022 were selected to evaluate the quality of medical records,and 856 qualified medical records were grouped according to the quality of medical records.144 unqualified medical records were included in the observation group.The clinical data of the two groups were compared,such as gender,age,education,professional title,length of hospital stay,and the influencing factors of medical record quality were analyzed by Logistic regression.Results:Among 1000 cases,856 were excellent,57 were good,42 were medium,31 were low,and 14 were poor.The defect rate was 14.4%(144/1000).The proportion of patients with age>50 years old and deputy chief physician in observation group was lower than that in control group,and the proportion of patients with hospital stay>10 days was higher than that in control group(P<0.05).Age,professional title and hospital stay were the factors influencing the quality of medical records(P<0.05).Conclusion:The quality of medical record filling still needs to be improved,which is affected by age,professional title,length of stay and so on.

关 键 词：耳鼻喉科 病案质量 现状调查 影响因素 

分 类 号：R197.32[医药卫生—卫生事业管理]