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目的分析某医院住院病案首页填写过程存在的问题,提出解决对策。方法根据国家卫生计生委《住院病案首页数据填写质量规范(暂行)》等文件规定,回顾性分析某医院2016年1月至2016年12月住院病案首页离院方式填写存在的质量缺陷问题,并将缺陷问题归纳进行总结,统计和分析。结果 2016年1月2016年12月检查了25 912份住院病案首页,填写有缺陷的435份,缺陷率1.68%,缺陷问题的条目数435条,其中非医嘱离院填写错误比例最高,填写错误率79.31%。结论离院方式的填写规范与否,直接影响到病案首页整体信息数据的准确性和完整性,医院应加强对新版住院病案首页规范化填写的培训,强化质量意识,提高病案书写的整体质量。
Objective To analyze the existing problems in the filling of the first page of hospitalized medical records in a hospital and put forward the solutions. Methods According to the regulations of the National Health and Family Planning Commission, “Home Quality Data of Inpatient Medical Records (Interim)” and other documents, a retrospective analysis was made on the quality defects in the first hospital outpatient form of a hospital from January 2016 to December 2016 Defects will be summarized to summarize, statistics and analysis. Results January 2016 In December 2016, 25 912 inpatient medical records were inspected, 435 defective copies were filled in, the defect rate was 1.68%, and the number of defects was 435, of which the non-medical prescriptions had the highest percentage of errors and the highest percentage of omissions Rate 79.31%. Conclusions The specification of the method of leaving the hospital directly affects the accuracy and completeness of the whole information data of the first page of the medical record. The hospital should strengthen the training on the standardization of the first page of the new inpatient medical record, strengthen the awareness of quality and improve the overall quality of medical record writing.