1803份拟诊讨论缺陷病案质量分析  

Quality Analysis of Defective Medical Records in 1803 Proposed Diagnostic Discussions

作　　者：丁玲[1] 王莹[1] Ding Ling;Wang Ying(Department of Medical Record Management,the First Medical Centre,Chinese PLA General Hospital,Beijing 100853,China;不详)

机构地区：[1]解放军总医院第一医学中心病案管理科,北京市100853

出　　处：《中国病案》2024年第11期14-16,共3页Chinese Medical Record

摘　　要：目的分析终末病案的首次病程记录拟诊讨论的书写缺陷,提出改进措施,以加强病案质量管理,提高病案的内涵质量。方法调取某综合性三甲医院2021年1月1日-2022年12月31日期间58552份终末病案的质控检查记录,将存在拟诊讨论缺陷的病案进行分类分析。结果1803份拟诊讨论缺陷病案中,书写缺陷最多的是拟诊讨论未结合病情提出鉴别点或未展开分析,共681份,缺陷占比37.77%;诊断依据缺陷469份,缺陷占比26.01%;诊断明确未讨论治疗及预后的341份,缺陷占比18.91%;未结合病情提出最佳治疗方案303份,缺陷占比16.81%。外科缺陷占比38.99%,内科缺陷占比35.66%。结论首次病程记录的拟诊讨论缺陷问题较多,应加强其规范化书写,增强医师对疾病分析诊断的能力和对疾病治疗预后的认识,促进病案内涵质量及医疗质量的共同提高。Objectives This study aims to analyze the defects of the first medical record and discussion of the proposed diagnosis in the final medical record writing,and seek improvement measures,so as to strengthen the quality management of medical records and improve the connotation quality of medical records.Methods 58,552 terminal medical records were retrieved from a comprehensive tertiary hospital from January 1,2021 to December 31,2022.The defective diagnosis discussions were classified by quality defects and statistical analysis was performed on the data.Results In the 1803 records,the most common writing defect in the proposed diagnosis discussion was that different diagnosis did not propose differential points/expansion based on the condition,accounting for 37.7%.In addition,there were 469 defective diagnostic bases,accounting for 26.01%of the total.341 reports with a clear diagnosis but no discussion of treatment and prognosis,accounting for 18.91%of the total.303 reports failed to propose the best treatment plan based on the patient's condition,accounting for 16.81%of the total.Among the medical and surgical records,surgical defects accounted for 38.99%and internal medicine defects accounted for 35.66%.Conclusions In the quality control of medical records,it was found that there were serious deficiencies in the first medical course record,proposed diagnosis and discussion.It is necessary to strengthen its standardized writing,enhance the ability of physicians to analyze and diagnose diseases,deepen their understanding of disease treatment prognosis,and promote the joint improvement of the connotation and quality of medical records and medical care.

关 键 词：首次病程记录 缺陷 质量分析 

分 类 号：R197.323[医药卫生—卫生事业管理]