三级公立医院临床医师对住院病案首页填写规范的知信行研究  

Study on Knowledge,Attitude and Practice of Clinicians in Tertiary Public Hospitals about Specification for Filling in the Front Page of Medical Records

作　　者：刘立煌 张霞[1] 窦雪琳 黄丽巧 Liu Lihuang;Zhang Xia;Dou Xuelin;Huang Liqiao(Peking University People's Hospital,Beijing 100044,China;不详)

机构地区：[1]北京大学人民医院,北京市100044 [2]北京大学血液病研究所,国家血液系统疾病临床医学研究中心,北京市100044

出　　处：《中国病案》2025年第3期15-19,共5页Chinese Medical Record

基　　金：国家卫生健康委医院管理研究所2024年医疗质量(循证)管理研究立项项目(YLZLXZ24G089);北京大学人民医院研究与发展基金(RDM2023-14);国家卫健委卫生健康统计工作高质量发展揭榜攻关课题(国卫办规划函[2022]336号(5))。

摘　　要：目的调查三级公立医院临床医师对住院病案首页填写规范(后文简称规范)的知信行现状,为进一步加强住院病案首页的规范管理提供参考。方法2024年1月2日—19日采用便利抽样方法对北京某大型三级公立医院临床医师进行规范知信行问卷调查,共发放问卷150份,回收有效问卷135份,采用描述性分析。结果临床医师对规范表示比较熟悉/熟悉的占54.82%,对主要诊断选择原则理解正确的占60.74%。超过80%的临床医师认为规范的学习和遵守重要/很重要,但只有69%的临床医师对于规范对管理指标的促进作用表示肯定。临床医师在实际填写主要诊断时以规范为依据的仅占39.26%。结论临床医师存在对规范的知晓程度不高、作用认同不强、使用率不高、主要诊断选择的原则掌握不够、行为异化风险等问题。建议完善培训内容和形式,加强培训考核和住院病案首页质控,更新细化规范,优化DRG/DIP等管理制度,共同构建住院病案首页规范填写的健康生态。Objectives This study aims to investigate the current situation of clinicians'knowledge,attitude and practice about the specification for filling the front page of medical records(hereinafter referred to as the specification)in tertiary public hospitals,so as to provide reference for further strengthening the standardized management of the front page of medical records.Methods From January 2 to 19,2024,a questionnaire survey was conducted among clinicians in a large tertiary public hospital in Beijing by convenient sampling method.A total of 150 questionnaires were distributed and 135 valid questionnaires were collected.Results 54.82% of the clinicians were relatively familiar/familiar with the specification,and 60.74% correctly understood the main diagnostic selection principles.80% of clinicians believed that learning and complying with the specification was important/very important,but only 69% of clinicians were positive about the promotion of the specification to management indicators.Only 39.26% of clinical physicians actually used specification as the basis for filling in the main diagnosis.Conclusions Clinical physicians have problems such as low awareness of the specification,weak recognition of their role,low utilization rate,insufficient grasp of the principles of major diagnostic selection,and risk of behavioral alienation.It is recommended to improve the content and format of training,strengthen training assessment and quality control of the inpatient medical record front page,update and refine the specifications,optimize DRG/DIP and other management systems,and jointly build a healthy ecology for the standardized filling of the inpatient medical record front page.

关 键 词：住院病案首页填写规范 知信行 DRG DIP 国家公立医院绩效考核 

分 类 号：R197.323[医药卫生—卫生事业管理]