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目的:研究分析病案首页存在的缺陷,并提出相应的控制措施,以减少病案首页填写差错的发生。方法:收集2014年1~10月(整改之前)与2015年1~10月(整改后)本院病案首页填写方面的资料,分析病案首页填写所存缺陷,提出相关控制措施,并予以落实,比较分析整改前后病案填写差错情况。结果:病案首页填写存在的缺陷有转归不准确、出院诊断顺序混乱、损伤中毒外部原因不明确、入院情况不完整以及院内感染等,整改后病案首页填写差错率明显下降(P<0.05)。结论:基于病案首页填写所存缺陷的分析施予相应的控制措施,及时且有效地予以改进,加强全程质控和终末质控,对于减少病案首页填写差错率和提高医院病案管理质量有着重要作用。
Objective: To study and analyze the existing defects in the first page of the medical record and to put forward the corresponding control measures to reduce the occurrence of the first page of the medical record. Methods: Collecting the first page of medical records of our hospital from January to October 2014 (before rectification) and January to October of 2015 (after rectification), collecting the defects on the front page of the medical records, putting forward the relevant control measures and implementing them, comparing Analysis of the case before and after rectification to fill in the error situation. Results: There were some defects in the first page of the medical records, such as inaccurate prognosis, disorder in discharge diagnosis sequence, unclear external causes of injury poisoning, incomplete admission and nosocomial infection. After the rectification, the error rate of filling in the first page of medical record was significantly decreased (P <0.05). Conclusions: The corresponding control measures should be given based on the analysis of the first page of the medical records, and the improvement should be made in a timely and effective manner. The improvement of quality control and end-of-life control should play an important role in reducing the error rate and improving the quality of medical records management .