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目的通过对近两年某院出院患者的入院病情进行统计,分析入院病情的填写和统计过程中存在的问题,并针对填写规范和报表统一问题提出改进措施。方法对某院2013年-2014年全院出院病例的入院病情进行统计、汇总,采用Excel 2007和SPSS19.0进行数据整理和统计分析。结果 2013年和2014年主要诊断中入院病情4(无)所占比例分别为0.18%和0.21%;所有诊断中入院病情4(无)的病例数所占比例分别高达3.21%和4.15%;入院病情“无”的误判率较高,2013年和2014年误判率分别高达40.73%和32.59%。结论住院病案首页入院病情填写质量不容乐观,入院病情4(无)的错判率较高,同时入院病情的统计亟需规范和统一,入院病情4(无)应统计所有诊断。
Objective To make statistics on the hospitalization of discharged patients in a hospital in the last two years, analyze the problems in the filling of the condition of admission and the statistical process, and put forward the improvement measures in accordance with the standardization of forms and the unification of statements. Methods A total of hospital discharges from 2013 to 2014 in a hospital were collected and analyzed. Data were collected and statistically analyzed using Excel 2007 and SPSS 19.0. Results The prevalence rates of admission 4 (none) in major diagnoses in 2013 and 2014 were 0.18% and 0.21%, respectively; all the cases with 4 (no) hospitalizations accounted for up to 3.21% and 4.15% of cases, respectively The misjudgment rate of illness “no ” was higher, and the false positive rates in 2013 and 2014 were as high as 40.73% and 32.59% respectively. Conclusion The quality of home admission should not be optimistic. The rate of misdiagnosis of admission 4 (none) is higher, and the statistics of admissions need to be regulated and unified.