摘要
目的:统计病案中患者信息修改原因的数据,对比实施对策的成效分析,为医院管理提供参考依据。方法:将2017年、2018年两年内登记的患者信息修改数据分类统计后采用EXCEL进行对比分析。结果:患者信息修改原因主要以患者姓名同音不同字修改为主,占65.23%,姓名、年龄全部修改的较少,占3.37%。针对患者基本信息的错误,2018年实施干预对策后,患者信息修改的例数较2017年有所减少。结论:患者信息修改存在诸多隐患,医院应通过加强管理,制定患者信息修改的相关规定,不断完善相关流程,以减少患者信息错误的发生,保证患者信息的准确性。
Purpose:To Statistic the data of the reasons for the modification of patients’information in medical records,comparative analysis of the effectiveness of the implementation of countermeasures,to provide a reference basis for hospital management.Method:The modified data of patients registered in 2017 and 2018 were classified and analyzed by EXCEL.Result:The main reason for the modification of patient information was the modification of patients’names with different homophones,accounting for 65.23%,and the modification of all names and ages was less,accounting for 3.37%.In view of the errors in the basic information of patients,after the implementation of intervention countermeasures in 2018,the number of patients with information modification was reduced compared with that in 2017.Conclusion:There are many hidden dangers in the modification of patient information.Hospitals should strengthen management to formulates relevant regulations on the modification of patient information and constantly improves relevant processes,so as to reduce the occurrence of patient information errors and ensure the accuracy of patient information.
作者
刘春香
于家增
陆琴
文淑君
马敏敏
周广良
LIU Chunxiang;YU Jiazeng;LU Qin;WEN Shujun;MA Minmin;ZHOU Guangliang(Medical Office,Ruihua hospital of Soochow University,Suzhou,Jiangsu,215000)
出处
《江苏卫生事业管理》
2021年第1期51-53,60,共4页
Jiangsu Health System Management
关键词
患者
病案
信息错误
原因分析
patient
medical record
information mistake
reason analysis
