论文部分内容阅读
对廉江市人民医院病案首页进行抽查检测后发现,本院病案首页的书写中存在较多缺陷,主要有患者基本信息不完整、诊断填写不规范、损伤、中毒等不完整或漏填、医院感染、病例诊断漏填。对这些缺陷造成的原因进行分析,其中有病人入院时无法提供有效身份证明或语言沟通障碍、部分医师存在专业水平较低或高级医师责任心不到位,针对以上问题提出了相关建议,如对实习医师进行临床病案首页书写培训,加强医院管理层对病案首页的重视程度并进行定期测评,病案整理人员中返聘经验丰富的医师进行病案整理,对于不合格的病案定期回返至各科室,加强编码员业务能力等等。病案首页填写完整具有重要意义,为各项医疗数据以及疾病相关研究提供了数据基础。
The first page of the case of Lianjiang City People’s Hospital for random inspection found that there are many defects in the hospital home page writing, there are incomplete basic information of the patient, the diagnosis is not complete, injury, poisoning incomplete or missing fill, the hospital Infection, case diagnosis leak fill. The causes of these defects are analyzed. Among them, patients can not provide effective identification or language barriers when they are admitted to hospital. Some doctors have lower professional level or senior physician’s sense of responsibility is not in place. Suggestions on the above issues are put forward, Physicians to write the first page of clinical medical records training to strengthen the hospital management of the importance of the first page of the medical records and regular evaluation of the record staff to recruit experienced physicians for medical record consolidation, Business skills and more. It is of great significance to complete the first page of the medical record, which provides the data basis for various medical data and disease related research.