住院病案首页出院诊断填写缺陷分析及改进措施研究  

Research on Defect Analysis and Improvement Measures of Discharge Diagnosis Filling in the Front Page of Inpatient Medical Records

作　　者：刘全红 徐佳 单蓓兰 LIU Quanhong;XU Jia;SHAN Beilan(Medical Department,Shanghai Liqun Hospital in Putuo District,Shanghai,200062 China;Information Science,Shanghai Liqun Hospital in Putuo District,Shanghai,200062 China)

机构地区：[1]上海市普陀区利群医院医务科,上海200062 [2]上海市普陀区利群医院信息科,上海200062

出　　处：《中国卫生产业》2024年第4期66-68,72,共4页China Health Industry

摘　　要：目的探究住院病案首页出院诊断填写缺陷分析及改进措施。方法选择2021年1月—2023年6月上海市普陀区利群医院收治住院患者的病案首页信息为研究对象,于2021年1—12月8000例患者病案首页信息采用常规管理模式(对照组),于2022年8月—2023年6月8000例患者病案首页信息采用优化改进管理模式(研究组),病历抽查方式为院内重点科室病历,分析两组住院病案首页出院诊断填写缺陷发生率以及住院病案首页管理质量。结果研究组出院诊断填写缺陷遗漏其他诊断、诊断不规范、主要诊断选择错误共发生68例,占比0.85%;对照组上述缺陷共计157例,占比1.96%,研究组低于对照组,差异有统计学意义(χ^(2)=35.707,P<0.05);研究组病案管理出院诊断填写准确性(78.96±2.84)分、规范化(80.22±2.97)分、完整性(80.25±2.33)分均高于对照组(62.69±2.45)分、(65.69±2.84)分、(63.96±2.98)分,差异有统计学意义(t=387.985、316.257、385.174,P<0.05)。结论住院病案首页出院诊断填写缺陷实施改进措施后有所改善,在今后的病案管理中,需要加强关于临床医师的管理研究,同时积极展开病案首页信息填写规范性培训,采取有效的管理措施,提高病案首页信息质量。Objective To explore the defect analysis and improvement measures of discharge diagnosis filling in the first page of inpatient medical records.Methods From January 2021 to June 2023,the first page information of medical records of inpatients admitted to Liqun Hospital of Putuo District in Shanghai was selected as the research object.From January to December 2021,the first page information of 8000 patients was managed by routine management mode(control group).From August 2022 to June 2023,the first page information of 8000 patients was managed by optimized and improved management mode(study group).The medical records of key departments in the hospital were randomly selected.The incidence of discharge diagnosis and filling defects on the first page of medical records and the management quality of the first page of medical records in the two groups were analyzed.Results In the study group,there were 68 cases of missing other diagnosis,non-standard diagnosis and wrong choice of main diagnosis in the discharge diagnosis,accounting for 0.85%,there were 157 cases of the above defects in the control group,accounting for 1.96%,the study group was lower than the control group,and the difference was statistically significant(χ^(2)=35.707,P<0.05).The accuracy(78.96±2.84)points,standardization(80.22±2.97)points and integrity(80.25±2.33)points of the discharge diagnosis of the medical record management in the study group were higher than those in the control group(62.69±2.45)points,(65.69±2.84)points,(63.96±2.98)points,the difference was statistically significant(t=387.985,316.257,385.174,P<0.05).Conclusion The defects of filling in the first page of hospitalization medical records have been improved after the implementation of improvement measures.In the future medical records management,it is necessary to strengthen the management research on clinicians,and actively carry out normative training on filling in the first page information of medical records,and take effective management measures to improve the quality of

关 键 词：住院病案 出院诊断 填写缺陷 改进措施 

分 类 号：R197[医药卫生—卫生事业管理] R323[医药卫生—公共卫生与预防医学]