三明市第一医院2011-2015年死亡病例报告质量分析

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目的了解三明市第一医院死亡病例报告质量。方法利用三明市第一医院2011—2015年死因监测个案库,评价死亡病例报告质量。结果 2011—2015年该院共有1 398张死亡报告卡,“死亡-录入”为4.0d(P50),7d及时率为69.8%;“录入-审核”为2.0d(P50),24h及时率为49.0%,均呈逐年上升趋势。不同类别死因中以慢性非传染性疾病居多(87.6%)。根本死因编码错误34例(2.4%)。结论应加强人员培训,强化责任意识,落实督导检查,切实提高医疗机构死亡病例报告质量。 Objective To understand the reported quality of death cases in the First Hospital of Sanming City. Methods Using the case control database of the first hospital of Sanming from 2011 to 2015 to evaluate the quality of the death cases. Results A total of 1 398 death report cards were reported in the hospital from 2011 to 2015, with a “death-entry” of 4.0 d (P50), a timely rate of 69.8% at 7 days, a " 24h timely rate was 49.0%, all showed an upward trend year by year. The majority of chronic non-communicable diseases among the different categories of cause of death (87.6%). Fundamental cause of death coding error 34 cases (2.4%). Conclusion The training of personnel should be strengthened, the sense of responsibility should be strengthened, the supervision and inspection should be implemented to effectively improve the quality of the report of death cases in medical institutions.
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