摘要
目的通过分析乳腺癌住院病案首页中诊疗信息的缺陷,寻求针对性解决方案,加强质量管理。方法自某院病案科病案管理系统调取2016年1月1日至-2018年12月31日期间以乳腺癌住院并行手术治疗的118例病例,按照《住院病案首页数据填写质量规范(暂行)》相关规定进行专项检查。结果118例乳腺癌住院病案首页中诊疗信息总缺陷频次为192例次,诊断信息缺陷144例次,占比75%,手术相关信息缺陷48例次,占比为25%。诊断信息中主要诊断信息缺陷67例次,占比46.53%,其他诊断信息缺陷43例次,占比29.86%,入院病情填写错误23例次,占比15.97%;手术信息中主要手术选择错误5例次,占比10.42%,其他手术操作填写缺陷17例次,占比35.42%,手术级别填写错误18例次,占比37.50%,手术切口/愈合等级漏填写4例次,占比8.33%。结论乳腺癌住院病案首页中诊疗信息的填写质量函待提高,需要重点加强住院病案首页填写的专项培训,提升临床医师对疾病诊断、手术描述能力及病案书写水平,从而提高住院病案首页的数据质量,促进乳腺癌病科的质量管理。
Objective To seek targeted solutions to improve quality management by analyzing the shortcomings of diagnosis and treatment information in the homepage of the breast cancer.Methods Investigate the 118 cases that patients were hospitalized and operated from medical records management system of a hospital from January 1,2016 to December 31,2018,and execute special check according to relative regulations such as The quality specifications of homepage data in hospital records.Results In the first page of 118 cases of breast cancer,defects of diagnosis and treatment information happened 192 times while defects of diagnosis occurred 144 times,accounting for 75%,and defects of surgical-related information was 48 times,accounting for 48%.There were 67 cases of major diagnostic information defects in the diagnosis information,accounting for 46.53%,43 cases of other diagnostic information defects,accounting for 29.86%and 23 cases that admission condition was incorrectly recorded,accounting for 15.97%.In the surgical information,5 cases that major surgery was selected incorrectly happened,accounting for 10.42%;17 cases ofdefects ofother surgery operation appeared,accounting for 35.42%.The defects of wrong surgical level happened 18 times,accounting for 37.50%,while defects that surgical incisions/healing levels were missed occurred 4 times,accounting for 8.33%.Conclusion The quality of filling out the diagnosis and treatment information in the first page of breast cancer cases and medical records needs to be improved.In order to improve the data quality in the first page of medical records and promote the quality management of cases of breast cancer,special training on filling in the first page should be performed which improve the clinicians’ability to diagnosis the disease,describe the operation and write the medical records.
作者
吴晓东
Wu Xiaodong(The People's Hospital of QingCounty,Qing 062650,Hebei Province,China)
出处
《中国病案》
2020年第2期19-21,共3页
Chinese Medical Record
关键词
乳腺癌
病案首页
诊疗信息
缺陷
Breast cancer
First page of medical record
Medical information
Defect
