摘要
目的掌握2012版病案首页入院病情填写情况,探索提高入院病情填写质量的方法。方法对某院2012年1月-3月6844份出院病案首页中的主要诊断入院病情项目进行归类汇总,检查分析。结果 6844份出院病案首页中主要诊断入院病情为临床明确诊断的5852例,占85.5%,填写错误率0.22%;临床未确定诊断的664例,占9.7%,填写错误率9.79%;情况不明的143例,占2.1%,填写错误率5.59%;入院时无,入院后新发生的185例,占2.7%,填写错误率47.03%,是入院病情填写准确性最低的一项。结论加强对临床医师关于入院病情选项含义及填写要求的讲解,要求医师重视问诊与沟通,利用计算机进行入院病情的监测,减少填写错误,提高填报正确率。
Objectives To acquire the filling situation of admitted diseases state in the home pages of medical records of 2012 version,and investigate methods to improve the filling quality of admitted diseases state.Methods To conduct classification,summary and inspection analysis on the admitted diseases state of principle diagnoses in the home pages of 6844 cases discharged medical records from January to March in 2012 of a hospital.Results There were 5852 cases of definitely clinical diagnoses in the principle diagnoses of admitted diseases state in home pages of 6844 cases discharged medical records,which took 85.5％,the error filling rate was 0.22％; 664 cases had no definitely clinical diagnoses,which took 9.7％,the error filling rate was 9.79％; Unknown cases were 143,which took 2.1％,the error filling rate was 5.59％; 185 cases were newly found after admitted,which took 2.7％,the error filling rate was 47.03％,and were the items with the lowest accuracy.Conclusions We should strengthen the explanation of the definition of admitted disease status items as well as filling requirements to clinical doctors,advise doctors attach importance to inquiry and communication,decrease filling errors and improve its accuracy through monitoring the admitted diseases state with the application of computers.
出处
《中国病案》
2015年第1期28-29,共2页
Chinese Medical Record
关键词
病案首页
入院病情
填写质量
分析
Home pages of medical records of 2012 version
Admitted diseases state
Filling quality
Analysis
