摘要
目的通过对某医院新生儿科医嘱转院住院病案首页数据分析,为新生儿科高质量发展提供参考依据。方法选取某医院2016年1月1日-2020年12月31日,新生儿科出生体重<2500克及≥2500克,且住院时间<5天且为医嘱转院的住院病案首页数据3343份,分析医嘱转院占比、出生体重、主要诊断、结局的绝对值及构成比等情况,统计学采取卡方及T检验进行差异性分析。结果新生儿科医嘱转院的占比逐年下降,从2016年的42.1%下降到2020年的12%;出生体重<2500克及≥2500克的医嘱转院数据占全部医嘱转院数据的比例分别为47.7%及52.3%,占同等出生体重比例分别为40.4%及21%,其中出生体重<1500克医嘱转院数据占全部医嘱转院数据比例14.7%,占同等出生体重比例为71.7%。出生体重<2500克及≥2500克的医嘱转院的病案首页数据中,主要诊断占比较高的分别为新生儿呼吸窘迫综合征及新生儿肺炎,占比15.2%及13.5%。结论新生儿科医嘱转院的占比呈现逐年下降趋势,医院应逐步降低出生体重<1500克、新生儿呼吸窘迫综合征等疑难重症的医嘱转院比例,建立合理的医嘱转院适应证。
Objectives This study aims to analyze the transfer data of neonatal pediatric orders on the medical record front pages in a hospital and provide a reference for the high-quality development of the neonatal department.Methods Data from 3343 medical record front pages of transfer cases of neonatal pediatric orders with birth weight<2500 grams and≥2500 grams in the neonatology department and hospitalization time<5 days from January 1,2016 to December 31,2020 were selected.The proportion of doctor's transfer,birth weight,main diagnosis,absolute value,and the composition ratio of outcomes,etc.were analyzed.The chi-square and T test were used for statistical analysis of differences.Results The proportion of transfer cases of neonatal pediatric orders decreased year by year,from 42.1%in 2016 to 12%in 2020.The proportions of doctor’s referral data for birth weight<2500g and≥2500g accounted for 47.7%and 52.3%of all doctor’s referral data,respectively,and accounted for 40.4%and 21%of the same birth weight.Among them,the data of birth weight<1500 grams accounted for 14.7%of all doctor's transfer data and accounted for 71.7%of the same birth weight.Among the homepage data of medical records with birth weight<2500 grams and≥2500 grams,the main diagnoses accounted for a relatively high proportion of neonatal respiratory distress syndrome and neonatal pneumonia,accounting for 15.2%and 13.5%respectively.Conclusions The proportion of the transfer cases of neonatal pediatric orders showed a downward trend year by year.Hospitals should gradually reduce the proportion of referrals for difficult and severe diseases such as birth weight<1500 grams and neonatal respiratory distress syndrome,and establish reasonable indications for referrals.
作者
付婷辉
侯东敏
郭默宁
冷京倍
阴赪宏
Fu Tinghui;Hou Dongmin;Guo Moning;Leng Jingbei;Yin Chenghong(Beijing Obstetrics and Gynecology Hospital,Capital Medical University.Beijing Maternal and Child Health Care Hospital,Beijing 100006,China;不详)
出处
《中国病案》
2023年第5期53-55,共3页
Chinese Medical Record
关键词
新生儿
医嘱转院
住院病案首页
出生体重
主要诊断
Neonate
Transfer cases of neonatal pediatric orders
Medical record front page
Birth weight
Principal diagnosis
