论文部分内容阅读
目的为了促进中医电子病案首页质量的提高,对某院中医电子病案首页填写质量存在问题进行分析。方法对2010年出院中医病案18,320份进行书写质量检查,分析存在问题根源。结果发现出院的中医电子病案首页18,320份,其中存在使用西医诊断、中医治疗类别填写错误问题的有1726份,占出院中医电子病案的9.42%。结论问题存在根源主要是对中医病案首页资料的重要性认识不足,对病历书写基本规范不了解,相关业务知识匮乏。针对问题,采取强化中医诊断相关业务培训,反复强调病案首页填写的重要性,改进制约措施后,中医病案首页填写质量有明显提高,缺陷病案首页由原来的9.42%降低到4.6%。
Objective To promote the improvement of the quality of the first page of TCM electronic medical records and to analyze the existing problems in the first page of TCM electronic medical records in a hospital. Methods A total of 18,320 medical records of discharged TCM patients in 2010 were inspected for writing quality and the root causes of the problems were analyzed. As a result, 18,320 first-line medical electronic medical records were released. Of these, 1726 were filled in using Western medical diagnosis and were incorrectly typed in Chinese medical treatment categories, accounting for 9.42% of the total number of discharged TCM medical records. Conclusions The root causes of the problems are mainly the lack of understanding of the importance of the first page of medical records, the lack of understanding of the basic norms of medical records writing and the lack of relevant business knowledge. In response to the issue, we strengthened the training of TCM-related businesses, repeatedly emphasized the importance of filling the first page of medical records and improved the control measures. The first page of Chinese medical records has been significantly improved in quality and the first page of defective medical records has been reduced from 9.42% to 4.6%.