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目的了解医院恶性肿瘤填报质量现况,促进医疗单位上报疾病工作制度化,规范化;方法选择我院2008年1月-2009年12月13103例恶性肿瘤填报卡,统计迟报率;结果 2008年迟填报率为2.36%。按构成比顺位排序前三位为头颈科,胸科和腹腔科。2009年迟填报率为1.83%。按构成比顺位排序前三位为腹腔科,头颈科和胸科。数据经过χ2检验,χ2=4.52,P<0.05,有统计学差异;结论通过加强医院病案质量管理环节,以及网络报病工作开展,大大降低了迟填报现象,从而提高医师对恶性肿瘤报表工作重要性的认识和病历书写的专业水平。
Objective To understand the current situation of the quality of reporting of malignant tumors in hospitals and promote the institutionalization and standardization of disease reporting in medical units.Methods 13103 cases of filing cards of malignant tumors in our hospital from January 2008 to December 2009 were selected, Fill rate of 2.36%. By order of composition of the top three for the head and neck, thoracic and abdominal tracts. Late filing rate in 2009 was 1.83%. According to the composition of the order of the top three for the abdominal cavity, head and neck and thoracic department. Χ2 = 4.52, P <0.05, there is statistical difference; Conclusion By strengthening the hospital medical records quality management aspects, as well as the network reported disease work, greatly reducing the phenomenon of late reporting, so as to enhance the doctor’s report on the work of malignant tumors is important Sexual knowledge and medical record writing professionalism.