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目的检查某院住院病案首页,发现数据填写存在的缺陷,找出相应的改进措施。方法选取某院九个临床科室为DRG试点科室,随机抽取2016年1月至6月出院的其中583份病案,采用描述性方法,分析住院病案首页填写存在的缺陷。结果 583份住院病案首页填写有缺陷的共327份,填写缺陷率56.1%,常见的缺陷有主要诊断选择错误、诊断名称不规范、漏诊断、手术及操作名称不规范、漏登记操作、入院病情选择错误及病案首页项目填写不全。结论目前该院住院病案首页填写质量仍有较大提升空间。
Objective To check the first page of inpatient medical records of a hospital and find out the shortcomings in data filling and find the corresponding improvement measures. Methods Nine clinical departments of a hospital were selected as DRG pilot departments, and 583 cases were randomly selected from January 2016 to June. Descriptive methods were used to analyze the defects of the first page of inpatient medical records. Results A total of 327 cases were filled in the first page of 583 inpatient medical records, with a defect rate of 56.1%. Common defects include the main diagnostic errors, non-standard diagnosis, missed diagnosis, non-standard operation and operation names, Select the wrong home and medical record item incomplete. Conclusion At present, there is still much room for improvement in the quality of the first page of inpatient medical record in this hospital.