某三级医院危重患者住院病历质量分析  

Quality analysis of medical records of critical patients in a tertiary hospital

作　　者：朱艳艳 何小菁 陆玉莹 刘清海 ZHU Yanyan;HE Xiaojing;LU Yuying;LIU Qinghai(Yifu Hospital Affiliated to Nanjing Medical University,Nanjing 211100,China;Eye&ENT Hospital of Fudan University,Shanghai 200031,China;LongHua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine,Shanghai 200032,China)

机构地区：[1]南京医科大学附属逸夫医院,江苏南京211100 [2]复旦大学附属眼耳鼻喉科医院,上海200031 [3]上海中医药大学附属龙华医院,上海200032

出　　处：《现代医院》2024年第9期1381-1383,1387,共4页Modern Hospitals

基　　金：上海申康医院发展中心临床科技创新项目(SHDC12021607)。

摘　　要：目的对某院危重患者住院病历进行抽查,将结果进行分类汇总,分析存在的问题,究其原因,寻求提升病历书写质量的措施。方法从某院2022年12月1日—2023年11月30日出院的1117份危重患者住院病历中抽取330份。依据《病历书写基本规范(2010版)》《医疗质量安全核心制度要点》《住院病案首页数据填写质量规范(暂行)》的相关规定及要求,结合医院实际情况对所抽查危重患者住院病历进行质控。结果抽查的330份危重患者住院病历中,有缺陷的病历占45.15%,其中病历首页信息存缺陷率最高,达到56.38%;其次为病程记录缺陷,缺陷率达25.50%。在缺陷率最高的病历首页项目中,存在缺陷最多的是首页基本信息的漏填、错填,占总病历首页信息缺陷份数的28.57%;其次是转科科别漏填,占总病历首页信息缺陷份数的11.90%;重症监护室记录的填写缺陷与主要诊断选择错误占比相持平,达10.71%。结论危重患者住院病历缺陷内容集中在病历首页信息、病程记录、出院(死亡)记录、知情同意书、授权委托书上,科室之前缺陷率有一定差距,建议通过强化医师法律意识、优化信息系统功能、增强科室间的协调、加强病历书写培训力度、实行奖惩责任追究,加强对危重患者住院病历质量的管理,提升病历整体质量。Objective According to a random check of the hospital’s critical medical records,classify and summarize the results,analyze the existing problems and their causes,seek to improve the quality of medical record writing measures.Methods 330 out of 1117 critically medical records discharged from December 1,2022 to November 30,2023 were extracted.According to the related regulations and requirements of Medical Record Writing Standard(2010),Key Points of Medical Quality and Safety Core System,the Quality Specification for Filling in Front Page Data(Temporary)and Family Planning Commission,special quality control was carried out on the key items filled in on the medical record based on the actual situation of the hospital.Results Among the 330 critically ill medical records sampled,45.15%had defects,among which 56.38%had defects in the first page of medical records,and 25.50%had defects in the course of disease.In the first page of medical records with the highest rate of defects,the most common defects were the missing and wrong filling of the basic information on the first page,which accounted for 28.57%of the total number of defects,followed by the missing filling of the transferred departments,11.90%of the total number of information defects in the first page of medical records,and 10.71%of the total number of errors in filling in the intensive-care unit records and in choosing the main diagnosis were equal.Conclusion The defect content of critical medical record is concentrated on the information of the first page of medical record,the course of disease,the record of discharge(death),the informed consent and the authorization letter,it is suggested that we should strengthen doctors’legal awareness,optimize the function of information system,strengthen the coordination between departments,strengthen the training of medical record writing and pursue the responsibility of rewards and punishments,strengthen the management of the quality of critical patients’medical records,and improve the overall quality of medic

关 键 词：危重患者 病历质量 缺陷分析 

分 类 号：R197.323.1[医药卫生—卫生事业管理]