摘要
目的分析住院病案首页质量存在的问题,了解其中的原因,提出相应的改进对策。方法选取某医院2018年1月至2019年12月收集的15800例住院病案首页作为研究对象,分析病案首页存在的质量问题。结果15800例住院病案首页不合格率为1.35%(214/15800),主要表现为疾病编码错填或未填、主要诊断选择不准确、手术及操作编码未填。不合格住院病案首页科室分布排名前5的科室为普通外科、呼吸内科、消化内科、心血管内科、骨科。不合格住院病案首页诱发因素排名前3的因素为临床医师录入后未核对、无法判断入院病情的正确选择、医院信息系统传输故障导致。结论医院住院病案首页质量问题,要从增强责任心、加强培训工作、加大监督及考核力度等方面进行改进。
Objective:To analyze the problems existing in the quality of the first page of inpatient medical records,understand the reasons,and put forward corresponding countermeasures for improvement.Method:The first pages of 15,800 inpatient medical records from January,2018 to December,2019 in a hospital were selected as subjects to analyze the quality problems existing in the first page of medical records.Result:The rejection rate of the first page of 15,800 inpatients’medical records was 1.35%(214/15,800),which was mainly manifested as incorrect or incomplete disease code,inaccurate major diagnosis selection,and incomplete operation and operation code.Generally,the top 5 departments of unqualified inpatient medical records were surgery,respiratory medicine,gastroenterology,cardiovascular medicine and orthopedics.The top 3 inducing factors on the first page of unquali fied inpatient medical records were no check-up after the input by clinicians,no way to judge the correct choice of admission condition,and the transmission failure of hospital information system.Conclusion:The quality of the first page of hospital inpatient medical records should be improved from the aspects of strengthening the sense of responsibility,the training,and the supervision and assessment.
作者
邓玉萍
陈海燕
刘琳
李清香
莫新颖
朱兴爱
DENG Yu-ping;CHEN Hai-yan;LIU Lin;LI Qing-xiang;MO Xin-ying;ZHU Xing-ai(Department of medical records statistics,Qingxin District People’s Hospital,Qingyuan,Guangdong 511800,China)
出处
《现代医院管理》
2020年第4期35-37,共3页
Modern Hospital Management
关键词
住院病案首页
疾病编码
质量问题
医疗质量管理
home page of inpatient medical record
disease coding
quality issue
medical quality management
