摘要
目的 通过分析某康复医院病案首页填写缺陷,从而梳理缺陷原因,提出改进方式,不断提升病案首页书写质量。方法 选取2022年1月1日—2023年5月所有住院病案首页进行质控,将缺陷内容进行数据分析。结果 8675份病案中579份病案存在1条及以上缺陷,平均每份病案缺陷条数为1.17条。总体缺陷率为6.67%。缺陷分型:诊疗信息(534条,占比78.53%),患者信息(77条,占比11.32%),住院过程信息(69条,占比10.15%)。结论 住院病案首页缺陷较多,为提升病案首页填写正确率、准确率,通过加强培训与管理、信息化手段优化势在必行。
Objective To analyze deficiencies in filling out homepage of medical records of a rehabilitation hospital,identify causes of deficiencies,propose improvement methods,and improve quality of filling out medical record continuously.Methods The paper carried out quality control on homepage of inpatient medical records from January 1,2022 to May 2023,and analyzed data on defective contents.Results Out of 8675 medical records,there were 579 with one or more deficiencies,with average of 1.17 deficiencies per medical record,with overall deficiency rate of 6.67%.Deficiency classification:diagnosis and treatment information(534 pieces,accounting for 78.53%),information of patients(77 pieces,accounting for 11.32%),and hospitalization process information(69 pieces,accounting for 10.15%).Conclusion There are many deficiencies in homepage of inpatient medical records.It is imperative to strengthen training and management,and optimize information technology to improve accuracy of filling out homepage of medical records.
作者
程飞
CHENG Fei(Sichuan Bayi Rehabilitation Center/Sichuan Province Rehabilitation Hospital,Chengdu,Sichuan 611135)
出处
《智慧健康》
2024年第21期176-179,共4页
Smart Healthcare
基金
四川省医院协会医院管理科研专项资金项目《可行能力理论下康复患者生命质量影响研究》(项目编号:YG2331)。
关键词
住院病案首页
缺陷
质量管理
Homepage of inpatient medical records
Deficiencies
Quality control
