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目的分析某医院住院患者基本信息缺陷情况,提出干预措施。方法回顾性核查某院2016年1月-2016年6月住院患者基本信息,将缺陷信息按缺陷类型及科室分布情况等进行归类总结、统计和分析。结果 2016年1月-2016年6月住院患者基本信息47 879份,存在缺陷的8716份,缺陷率18.19%,其中缺陷发生率最高的是外科系统,缺陷率26.34%;妇产科系统缺陷发生率最低,为12.97%。结论规范住院患者基本信息采集登记流程及严格管理制度,强化责任意识和质量意识,加强环节质控,完善提升信息系统辅助功能,是提高患者基本信息完整性、准确性的有效干预措施。
Objective To analyze the basic information defects of inpatients in a hospital and propose intervention measures. Methods The basic information of inpatients from January 2016 to June 2016 in a hospital was retrospectively reviewed. The defect information was classified, summarized and analyzed according to the types of defects and the distribution of departments. Results From January 2016 to June 2016, there were 47 879 inpatients with 8716 defects, the defect rate was 18.19%. The highest incidence of defects was in the surgical system, with a defect rate of 26.34%. Obstetrics and gynecology system defects occurred The lowest rate was 12.97%. Conclusion It is an effective intervention to improve the integrity and accuracy of patients’ basic information by standardizing the basic information collection and registration process and strict management system of inpatients, strengthening the sense of responsibility and quality, strengthening the quality control and improving the auxiliary functions of information system.