摘要
[目的]分析延边地区某医院外科住院病案首页填写缺陷情况.[方法]收集延边地区某医院外科各科室27 828份住院病案首页信息,分析填写缺陷情况.[结果]烧伤整形科、妇科、骨科、口腔科和普通外科的病案首页出错率分别为8.89%,4.48%,4.35%,4.19%和4.08%,高于其他科室.[结论]延边地区某医院外科各科室住院病案首页填写缺陷情况较普遍.
OBJECTIVE To analyze the situation of filling in defects in the homepage of surgical hospital medical records of a hospital in Yanbian area.METHODS The information about 27 828 homepage of surgical hospital medical records of a hospital in Yanbian area was collected,and its filling in defects were analyzed.RESULTS The error rates in the homepage of medical record in the department of burns and plastic surgery,gynecology,orthopedics,stomatology and general surgery were 8.89%,4.48%,4.35%,4.19% and4.08% respectively,the error rate in these departments was higher than that in the other departments.CONCLUSIONIt was common for the filling in defects in homepage of surgical hospital medical record of a hospital in Yanbian area.
作者
崔延姬
全振喜
方今女
李医华
CUI Yanji QUAN Zhenxi FANG Jinnu LI Yihua(Affiliated Hospital of Yanbian University Yanbian University College of Medicine ： Yanji 133000, Jilin, China)
出处
《延边大学医学学报》
CAS
2016年第4期275-277,共3页
Journal of Medical Science Yanbian University
关键词
病案
首页
填写缺陷
medical record
homepage
filling in defect
