摘要
目的从管理与评价的角度构建病例分型首页关联指标逻辑体系。方法先在病案首页中找出与病例分型有逻辑关系的关联指标,然后以"不可能"、"可能"、"肯定"三种应答方式分别构建初始分型(入院时的分型)、复核归档分型(出院时的分型)与其关联指标之间的逻辑体系。结果在病例分型中初始分型(入院时的分型)与入院途径、入院病情、是否抢救、是否急诊手术有密切的逻辑关联性;复核分型(出院时的分型)与出院情况、抢救、手术级别、无菌切口愈合情况有密切的逻辑关联性。结论病例分型首页关联指标逻辑体系的构建有利于规范病案首页的填写,同时有利于病案管理部门在作病例分型管理与分析时建立多维度的评价体系。
Objective From management and evaluation＇s angle to Construct logical system for cases of disease categories＇s coupling indexs in the Front Page. Methods First, to find the cases of disease categories＇s coupling indexs, and then to build the logical system, through using ＂impossible ＂,＂ possible ＂,＂ Sure＂ to answer initial classification（ the classification on admission ）, and recheck filing classification（ the classification at discharge） o Results There was the close logical relations between initial classification （ the classification on admission ） and way of admission, disease of admission, emergency treatment, emergency operation; As the same between rechecking classification （ the classification at discharge） and disease of discharge, emergency treatment, Operation Classification, postoperative wound healing. Conclusion The construction of logical system for cases of disease categories＇s coupling indexs in the Front Page was beneficial to fill in the Front Page of medical record by standard, meanwhile facilitating medical record management department to built Multi - dimensional evaluation system for management and analysis of cases of disease categories.
出处
《现代医院》
2012年第3期132-134,共3页
Modern Hospitals
关键词
病例分型
首页指标逻辑体系
构建意义
Cases of disease categories, Medical Record Front Page, Indexes, Eogical system, Construction, Significance
