摘要
目的分析歧义病案产生的原因，为疾病相关组 （diagnosis related groups, DRGs）奠定基础。方法从2010年至2014年17751份手术病案首页中按照主要诊断与主要手术的选择原则筛选出歧义病案268份，采用单因素卡方检验分析不同住院特征对歧义病案的影响，将有显著性差异的变量赋值后采用Logistic回归分析寻找歧义病案产生的影响因素。结果17751份手术患者住院病案首页中共有歧义病案268份，占全部手术病案的1．51％。Logistic回归分析结果显示：内科出院、死亡患者、转科、高龄、住院时间长、肿瘤患者都是导致歧义病案产生的危险因素，结果均有统计学意义（P〈O．05），其中出院科别（OR=6．595，95％CI：5．043～8．625）、是否死亡患者（OR=3．787，95VooCI：2．611～5．492）和是否转科（0R：2．746，95％CI：2．061～3．659）是影响歧义病案发生率的重要危险因素。结论通过对歧义病案产生原因的分析，为医院有针对性地开展病案质量管理提供依据。
Objective Analyze the causes of ambiguous medical records to provide evidence for the DRGs. Methods 268 Ambiguous medical records were selected from 17 751 surgery medical records between 2010 and 2014 based on major diagnosis and major surgery. The single factor Chi-square test was used to study the influence of various inpatient characteristics on the occurrence of ambiguous medical records, and those significant variables were given assignment to find influencing factors of ambiguous medical records by using logistic regression analysis. Results Ambiguous medical records account for 1.51% of all surgical medical records. Logistic regression analysis results show that such risk factors as discharging from internal medicine, death of patient, transfer between departments, elderly, long time of hospitalization, and tumor patients, as contributing to ambiguous medical records. All the results are statistically significant （P〈0. 05）, including discharging from which departments （OR=6. 595, 95%CI： 5. 043-8. 625）, death of patient （OR=3. 787, 95%CI： 2. 611-5. 492） and transfer between departments （OR= 2. 746, 95% CI： 2. 061-3. 659）, which rank important risk factors for ambiguous medical records. Conclusion Analysis of the causes of ambiguous medical records provides important evidences for the hospital to improve its medical record quality management.
出处
《中华医院管理杂志》
北大核心
2015年第11期875-878,共4页
Chinese Journal of Hospital Administration
