摘要
目的对住院病案首页中出院诊断填写存在的问题进行分析,探寻正确书写出院诊断的有效措施。方法回顾性调查并分析2014年7月至9月住院病案首页出院诊断填写情况。结果 15335份出院病案首页中,出院诊断填写缺陷率为9.8%。出院诊断书写存在的主要问题是:主要诊断选择错误,疾病名称不规范,遗漏次要诊断,出院诊断与病案内容不符。结论针对部分医师主要诊断选择原则不清楚,疾病诊断命名不规范,组织临床医师开展专题培训与研讨;增强医生的责任意识,重视病案首页出院诊断的价值;发挥好编码人员与质控医师的双重把关作用,以提高出院诊断书写正确率。
Objectives To analyze the existing problems of discharge diagnosis in the front sheet of medical records, and explore effective measures to improve its accuracy of discharge diagnosis. Methods To conduct a retrospectively survey and analysis on the filling situations of home page in the medical records from July to September in 2014. Results The defect rate of discharge diagnosis was 9.8% in 15335 copies of home page of medical records. The main problems of discharge diagnosis writing was inaccurate principal diagnosis, non-standard disease names, omissions of secondary diagnosis, inconsistence with the content of medical records. Conclusions Aimed at the unclear selection rules of main diagnosis among some of the doctors and the non-standard disease diagnosis names, we should organize doctors to conduct special training and discussion, strengthen the responsibility awareness of them, pay attention to the value of discharge diagnosis in the home pages of medical records and give full play to the double supervision function of coding staff and quality control doctors, thus we could improve the accuracy of filling of discharge diagnosis.
出处
《中国病案》
2015年第9期27-28,共2页
Chinese Medical Record
关键词
病案首页
出院诊断
缺陷
Home page of medical records
Discharge diagnosis
Defects
