摘要
目的分析住院病案首页主要缺陷项目,探讨提高病案首页填写质量的方法。方法对2017年1月-3月病案首页存在缺陷的1909份病案进行分析,利用帕累托图找出病案首页的主要缺陷项目,并深入分析缺陷表现。结果病案首页缺陷总发生次数为1918次,涉及4个信息类型,29个缺陷项目。帕累托图显示,入院途径、手术及操作日期、医师签字、病理诊断、离院方式、婚姻6个缺陷为主要缺陷项目,累计构成比为77.11%。深入分析缺陷表现发现入院途径与病程记录描述不符和手术及操作日期与手术记录不符发生率相对较高,分别为26.44%和22.18%。结论通过加强科室及院内质控管理、开展多种样式培训、建立信息数据共享平台的方法提高病案首页质量。
Objective To analyze the primary defect items and to explore the ways to improve the quality of the front sheet. Methods Analysis of pareto diagram on 1909 defective in the front sheet of medical records from January to March 2017, and found out the primary defect items and performances. Results The total number of defects was 1918, involving 4 types and 29 defect items. Pareto diagram showed that 6 defects as the main defect items,and the cumulative composition ratio of 77.11%. The admission route not match medical records progress and the operation and operation date not match the surgical records were higher, respectively 26.44% and 22.18%.Conclusion A lot of emphasis should be put on the strengthen the department and the hospital quality control management, carry out a variety of style training, establishment of information sharing platform to improve the quality of the front sheet of medical records.
出处
《中国病案》
2017年第10期21-24,共4页
Chinese Medical Record
关键词
病案首页
缺陷
帕累托图分析
The front sheet of medical record
Defects
Pareto diagram analysis
