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目的分析住院病案首页主要缺陷项目,探讨提高病案首页填写质量的方法。方法对2017年1月-3月病案首页存在缺陷的1909份病案进行分析,利用帕累托图找出病案首页的主要缺陷项目,并深入分析缺陷表现。结果病案首页缺陷总发生次数为1918次,涉及4个信息类型,29个缺陷项目。帕累托图显示,入院途径、手术及操作日期、医师签字、病理诊断、离院方式、婚姻6个缺陷为主要缺陷项目,累计构成比为77.11%。深入分析缺陷表现发现入院途径与病程记录描述不符和手术及操作日期与手术记录不符发生率相对较高,分别为26.44%和22.18%。结论通过加强科室及院内质控管理、开展多种样式培训、建立信息数据共享平台的方法提高病案首页质量。
Objective To analyze the main defects in the first page of inpatient medical records and to explore ways to improve the quality of the first page of medical records. Methods A total of 1, 909 medical records with defects on the first page of the medical records in January-March 2017 were analyzed. Pareto charts were used to identify the main defects on the first page of the medical records and the defects were analyzed in depth. Results The total number of home page defect cases was 1918, involving 4 types of information and 29 defects. Pareto charts showed six major defects, including admission route, date of operation and operation, signature of physician, pathological diagnosis, leaving hospital, and marriage, with the cumulative ratio of 77.11%. In-depth analysis of the performance of the defects showed that the admission route was inconsistent with the description of the disease record and the incidence of the discrepancies between the operation and operation dates and the surgical records was relatively high, accounting for 26.44% and 22.18% respectively. Conclusion By strengthening department and hospital quality control management, carrying out a variety of style training, the establishment of information and data sharing platform to improve the quality of the first page of medical record.