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目的通过对工作中查获的错位病案的错位原因分析,在病案管理各环节不断整改,为降低病案在开放式固定病案架上的错误率提供参考。方法收集我院病案室2009年1月1日-2013年12月31日因需要提供病案时查找到或工作时无意中发现的错位病案611份,归纳整理有效数据进行统计分析。结果错位病案中因看错号码放错位置548份;再次住院归档时放错病案袋17份;两本病案装订或叠在一起归档19份;不连号的两个病案袋叠在一起上架27份。在病案归档各环节进行整改后,病案的错位率呈逐年下降趋势,2009年错位发生率0.49%,2010年为0.25%,2011年为0.21%,2012年为0.19%,2013年为0.10%,2009年有未找到的错位病案5份,2010年后基本没有发现找不到的错位病案。结论要达到病案管理零差错还需在工作中不断总结经验、整改,才能最大效率地发挥病案的作用。
Objective Through the analysis of the dislocation causes of dislocation cases found during the work, it is constantly revised in all aspects of the case management and provides reference for reducing the error rate of the case cases in open fixed case. Methods A total of 611 cases of dislocation cases that were found or were inadvertently found during the period from January 1, 2009 to December 31, 2013 were collected and analyzed statistically. Results Misdiagnosis of the wrong number due to misplaced 548 copies of the file; re-placed in the wrong file when hospitalized 17 cases; two medical records bound or stacked 19 filed; two cases of non-consecutive numbers stacked together shelves 27 Copies After the medical records were archived, the dislocation rate of medical records showed a downward trend year by year. The incidence of dislocation in 2009 was 0.49%, 0.25% in 2010, 0.21% in 2011, 0.19% in 2012 and 0.10% in 2013, In 2009, there were 5 cases of malposition that were not found. After 2010, no cases of misplaced cases were found. Conclusion To achieve zero error in case management, we must constantly sum up experience and rectification work in order to maximize the efficiency of medical records.