摘要
目的通过对2012版病案首页在信息系统中的设置的研究和临床填写首页的情况分析,探讨控制病案首页填写质量的方法。方法从信息系统中导出2012年10月份医生填写的病案首页所有项目,以Excel形式进行分类统计。结果病案首页有21个项目存在空项,最高空项率为62.86%,身份证号填写错误率为7.3%,在728个手术操作名称中,8.8%个手术操作名称级别填写不统一。结论强化培训是病案首页质量控制的基础,完善信息化是病案首页质量控制的重要手段,加强监控是病案首页质量控制的保证。
Objective To research the setting of the front sheet of medical records 2012 version in the information system and analyze the filling of clinicians, so as to discuss measures to control the quality of medical record filling. Methods Exporting all the items of front sheet of medical records in October 2012, making classified statistics with EXCELL. Results There are 21 empty entries in the front sheet and the highest rate is 62.86%. The error rate of ID number f＇tlling is 7.3 %, and 8.8% of the 728 surgical operation grade fillings are not uniform. Conclusions Intensive training, improving information construction and strengthening monitoring are the base, methods and guarantee for the front sheet quality control.
出处
《中国病案》
2013年第5期25-27,共3页
Chinese Medical Record
关键词
病案首页
质量控制
方法
The front sheet of Medical Record
Quality control
Methods
