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目的对住院病案首页中出院诊断填写存在的问题进行分析,探寻正确书写出院诊断的有效措施。方法回顾性调查并分析2014年7月至9月住院病案首页出院诊断填写情况。结果 15335份出院病案首页中,出院诊断填写缺陷率为9.8%。出院诊断书写存在的主要问题是:主要诊断选择错误,疾病名称不规范,遗漏次要诊断,出院诊断与病案内容不符。结论针对部分医师主要诊断选择原则不清楚,疾病诊断命名不规范,组织临床医师开展专题培训与研讨;增强医生的责任意识,重视病案首页出院诊断的价值;发挥好编码人员与质控医师的双重把关作用,以提高出院诊断书写正确率。
Objective To analyze the existing problems of filling out diagnosis in the first page of inpatient medical records and find out the effective measures to correctly diagnose discharged patients. Methods Retrospective investigation and analysis of the first hospital outpatient diagnosis in July-September 2014 were completed. Results 15,335 out of the first page of hospitalized cases, discharge rate of 9.8%. Discharge diagnosis written to write the main problems are: the main choice of diagnostic errors, the name of the disease is not standardized, missing minor diagnosis, discharge and medical records do not match the diagnosis. Conclusions Aiming at the unclear principle of selecting some doctors, the non-standard diagnosis of diseases, organizing special training and seminars for clinicians, strengthening the sense of responsibility of doctors and paying attention to the value of the first hospital outpatient diagnosis, and giving play to the duality of coders and quality control physicians Check function to improve the correct rate of discharge diagnosis.