摘要
目的:探讨规范填写病案首页对病案质量的影响作用,并分析规范填写病案首页的对策。方法:于2015年1月到2016年1月间,选我院8593份住院患者的病案进行回归性分析,根据《病历书写规范》中的相关内容对所有病案进行质量检查和分析,统计病案中存在病案首页填写及规范发生状况。结果:8593份病案中存在不规范填写病案首页1635份,占19.0%。不规范内容分类为:基本信息589份,占36.0%;诊断信息437份,占26.7%;手术信息214份,占13.1%;其他信息395份,占24.2%。结论:规范填写病案首页直接影响病案质量,临床需采取针对性措施,不断提升病案首页填写质量。
Objective： To explore the influence of the stan- dard of the medical record on the quality of the medical record, and analyze the Countermeasures of the standard. Methods： from January 2015 to January 2016, our hospital 8593 cases of inpatient medical records were analyzed retrospectively, the quality inspection and analysis of all medical records according to the relevant content of ＂Specification for writing of medical records＂ in the medical record and fill in the specification con- dition of existing statistical records. Results： there were 1635 cases in 8593 cases, which were not standardized, accounting for 19% of the cases. Nonstandard content classified as： basic information 589, accounting for 36%; diagnostic information 437, accounting for 26.7%; surgical information 214, accounting for 13.1%; other information 395 copies, accounting for 24.2%. Conclusion： the standard fill out the front page of medical record directly affects the quality of the medical record, the clini- cal need to take pertinent measures, and constantly improve the quality of the first page of the medical record.
作者
董建华
Dong Jianhua(The Information Department of the Second Affiliated Hospital of Luohe Med＆Cal College （462300)
出处
《黑龙江医药》
CAS
2017年第3期542-544,共3页
Heilongjiang Medicine journal
关键词
规范填写病案首页
病案质量
影响
Standard fill in the first page of medical re- cords
quality of medical records
influence
