摘要
目的通过抽查某院2016年01月至2016年06月归档的600份病案首页,进行质量检查,并对结果进行统计、分析,找出存在的缺陷与问题,为提高病案首页的填写规范提出改进措施。方法根据原卫生部《病案首页部分项目填写说明》及国家卫生计生委办公厅《住院病案首页数据填写质量规范(暂行)》(2016年版)的要求,抽查某院2016年01月至2016年06月份出院病案中病案首页600份,对病案首页填写缺陷情况进行分析研究。结果病案首页填写缺项、错项和书写不规范问题较多,检查的600份病案首页中,共有463份病案首页存在缺陷,缺陷率达77.2%。结论病案首页质量问题严重,医院各行政职能部门及临床科室应予以足够的重视,建立健全相关管理机制,加强培训与教育,完善信息系统,提升医师填写与病案管理人员审核病案首页的能力,从而提升病案首页填写质量。
Objective 600 cases of the front page of the medical records in a hospital from January to June of 2016 were selected and examined, and the results were analyzed to identify the existence of defects and problems, and to improve the standard rate of medical records. Methods According to the requirements of the ＂Filling in Instructions of Partial Items of New Edition of Medical Records＂ announced by the Health Planning Commission, and the ＂Inpatient Case Home Data Fill in Quality Specification（Temporary）＂（2016）, sample 600 cases of the front page of medical records of a hospital during 2016 from January to June, and analyze the filling in defects situation of home pages of medical records. Results The first page of the medical records of the missing, wrong and writing is not standardized problems, check the 600 cases of the firstpage, a total of 463 cases of the first case of defects, defect rate of 77.2%. Conclusions The quality problem of the front page of the medical records is serious, and the administrative departments and clinical departments of the hospital should pay enough attention to establish and improve the related management mechanism, strengthen training and education, improve the information system, and improve the ability of the physician to complete the home page of the medical records, so as to improve the quality of the first page of the medical records.
出处
《中国病案》
2018年第2期31-33,共3页
Chinese Medical Record
关键词
病案首页
缺陷
对策
Front page of medical records
Defect
Countermeasures
