摘要
目的分析某三级妇幼保健院住院病案首页问题,为提高住院病案首页质量提供指导。方法回顾性分析某三级妇幼保健院2019年1月1日-2019年12月31日住院病案首页10456例,统计并记录住院病案首页问题发生情况。结果住院病案首页存在问题649例,发生率为6.21%。住院病案首页问题类型分布情况按照占比从高到低的顺序依次为诊疗信息缺漏,住院信息缺漏、住院信息错误、患者信息缺漏、患者信息错误、妇婴卡问题,占比分别为38.98%、13.41%、13.25%、11.71%、2.62%、0.62%。信息未填问题分布中,最为常见的问题是盆腔粘连诊断或手术未填、引产操作未填,占比分别为10.32%、11.71%,均明显高于其他信息错误问题;而信息错误问题分布中,最为常见的问题是质控日期错误,占比14.33%,明显高于其它信息错误问题(均P<0.05)。结论某三级妇幼保健院全年住院病案首页问题应引起重视,可通过完善质控系统、加强绩效考核、培训指导以及反馈整改等干预降低其发生率。
Objectives To study and analyze the front page of inpatient medical records in a tertiary maternal and child health care hospital in order to provide guidance for improving the quality of the front page of inpatient medical records.Methods A retrospective analysis was performed on the frpnt page of 10456 inpatients in a tertiary maternal and child health care hospital from January 1st,2019 to December 31st,2019,and the occurrence of problems in the front page of inpatients'medical records was recorded.Results The number of problems occurred in the front page of inpatient medical records was 649,the incidence was 6.21%.The distribution of the types of questions on the first page of inpatient medical records in the order from high to low proportion were diagnosis and treatment information deficiency,hospitalization information deficiency,patient information deficiency,patient information error,and maternal and infant card problems,accounting for 38.98%,13.41%,13.25%,11.71%,2.62%,and 0.62%,respectively.In the distribution of problems with unfilled information,the most common problems were pelvic adhesion diagnosis,surgery and labor induction,accounting for 10.32%and 11.71%,respectively,which were significantly higher than other problems with incorrect information.In the distribution of information error problems,the most common problem was quality control date error,accounting for 14.33%,significantly higher than other information error problems(all P<0.05).Conclusions The front page of annual inpatient medical records in a tertiary maternal and child health care hospital should be paid more attention to,and the incidence may be reduced by improving the quality control system,strengthening performance assessment,training and guidance,feedback and rectification.
作者
陈芳
石晓君
Chen Fang;Shi Xiaojun(Department of Medical Record and Statistics,Nanshan Maternal and Child Health Hospital of Shenzhen,Shenzhen 518000,Guangdong Province,China;不详)
出处
《中国病案》
2021年第7期9-12,共4页
Chinese Medical Record
关键词
妇幼保健院
住院病案首页
问题
分析
质量控制
Maternal and child health care hospital
Front page of inpatient medical records
Problem
Analysis
Quality control
