摘要
目的通过对某医院2013年病案首页核心信息填写缺陷的分析,查找病案首页核心信息填写常见缺陷,为医院提高病案首页填写质量提供对策。方法对北京市卫计委病案首页填写专项检查抽查的200份2013年住院病案首页进行质控,对各类缺陷进行分类统计。结果主要诊断填写缺陷检出率为23%,其他诊断填写缺陷检出率为14%,手术和操作填写缺陷检出率为45.5%,附页重要信息填写错误检出率为30.5%,各项缺陷检出率均高于北京市三级医院平均水平。结论要重视病案首页信息的填写,加强临床医师和编码员的培训,强化病案质控的工作,规范临床医师病案首页填写,提高病案编码的质量。
Objectives To find out the common filling defects of the core information in home pages of medical records through the analysis on the filling defects of the core information in home pages of medical records in a hospital in 2013, and provide countermeasures for the improvement of filling quality of home pages in medical records of the hospital. Methods To conduct quality control on the 200 cases of home pages in the hospitalized medical records in 2013 which were checked specially by the Beijing Health and Planning Community, then make statistical classification on these various defects. Results The detection rate of filling defects of primary diagnosis was 23 %, while other diagnosis was 14%, the detection rate of operations was 45.5% and the detection rate of other important information in attached sheet was 30.5%, all these rates were higher than the average level of the three grade hospitals in Beijing. Conclusions We should attach importance to the filling of information of home pages in medical records, strengthen the training of clinical doctors and coding workers, enhance the quality control work of medical records, standardize the filling of home pages of medical records, thus to improve the coding quality of medical records.
出处
《中国病案》
2015年第7期14-16,共3页
Chinese Medical Record
关键词
病案首页
质量控制
缺陷分析
Home pages of medical records
Quality control
Defects analysis
