住院病案首页填写质量提升措施研究  

Research on measures to improve the quality of filling of hospitalization medical record homepage

作　　者：李化兵 杨增金 李玲玲 胡家华 佟振花 LI Huabing;YANG Zengjin;LI Lingling;HU Jiahua;TONG Zhenhua(Department of Pediatrics Ward 2,Zhucheng People's Hospital,Shandong Province,Zhucheng 262200,China;De partment of Obstetrics,Zhucheng Maternity and Child Health Care Hospital,Shandong Province,Zhucheng 262200,China;Standardization Construction Section,Zhucheng People's Hospital,Shandong Province,Zhucheng 262200,China;Department of Pediatrics,Affiliated Hospital of Shandong Second Medical University,Shandong Province,Weifang 261000,China;Department of Neurology Ward 4,Zhucheng People's Hospital,Shandong Province,Zhucheng 262200,China)

机构地区：[1]山东省诸城市人民医院儿科二病区,山东诸城262200 [2]山东省诸城市妇幼保健院产科,山东诸城262200 [3]山东省诸城市人民医院标准化建设科,山东诸城262200 [4]山东第二医科大学附属医院儿科,山东潍坊261000 [5]山东省诸城市人民医院神经内科四病区,山东诸城262200

出　　处：《中国当代医药》2025年第9期130-133,共4页China Modern Medicine

摘　　要：目的通过对病案首页的质控分析,找出问题的原因,制定改进措施,提升病案首页质量。方法随机抽取2024年1月1日至2024年5月31日诸城市人民医院出院病案5632份,37名质控员根据住院病案首页项目核查表进行质控和统计,质控内容包括患者基本信息、住院诊疗经过及诊疗信息两大部分共计46条项目。结果抽查的5632份住院病案首页,有空项、错误项等,分布于基本信息D类(49.99%)、住院诊疗信息A类(15.87%)、住院诊疗信息D类(15.2%)中。其中基本信息D类缺陷主要是工作单位、地址、职业、现住址、户口地址及邮编、地址及电话;住院诊疗信息A类缺陷以其他诊断漏填、主要诊断选择错误为主;手术信息缺陷以主要手术操作选择错误(7.63%)为主;住院诊疗信息D类缺陷主要是医疗组长、2级和3级护理天数、质控护士。结论通过质控发现病案首页缺陷多,需要加强各个环节人员的培训,不断完善首页质控管理及信息化手段建设。Objective Through the quality control analysis of the homepage of medical records,the causes of problems were identified,improvement strategies were formulated,and the quality of thehomepage of medical records was improved.Methods A total of 5632 discharged medical records from January 1,2024 to May 31,2024 were randomly selected from Zhucheng People's Hospital,and 37 quality controllers conducted quality control and statistics according to the homepage of inpatient medical records project checklist.The quality control included two major parts,namely,the patient's basic information and hospitalization diagnosis and treatment experience and information,with a total of 46 items.Results Among the 5632 ran-domly inspected inpatient medical records,there were omissions,blanks,and errors,distributed in basic information category D(49.99%),inpatient diagnosis and treatment information category A(15.87%),and inpatient diagnosis and treatment information category D(15.2%).Among them,the defects of basic information category D were mainly related to the workplace,address,occupation,current address,household registration address and postal code,address,and telephone number;the defects of inpatient diagnosis and treatment information category A were mainly due to the omission of other diagnoses and the incorrect selection of the main diagnosis;the defects of surgical information were mainly due to the incorrect selection of the main surgical operation(7.63%);the defects of inpatient diagnosis and treatment information category D were mainly related to the medical team leader,days of level 2 and level 3 nursing,and quality control nurses.Conclusion The quality control found that there were many defects in the homepage of medical records,and it was necessary to strengthen the training of personnel in various links,continuously improve the quality control management of the home-page,and strengthen the construction of information tech-nology means.

关 键 词：病案首页 质量改进 培训 信息化建设 

分 类 号：R197[医药卫生—卫生事业管理]