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目的分析烧伤科病案首页手术名称填写缺陷原因,探索提高质量方法。方法以病案首页填写规范和ICD-9-CM-3分类编码原则为标准,对某院烧伤科2012年1月至2014年12月病案随机检查100份,分析病案首页手术名称填写缺陷。结果共检查出缺陷病案24份,其中手术操作名称书写缺陷15份,主要手术操作选择错误6份,漏记手术操作名称3份。结论认识不足、知识缺乏、重视不够、质控不力是烧伤科病案首页手术操作名称填写存在缺陷原因。提高认识、加强培训、强化质控有助于提高病案首页质量。
Objective To analyze the causes of filling defects in the name of the first page of burn medical records and to explore ways to improve quality. Methods Based on the first page of the medical records and the ICD-9-CM-3 classification and coding principle, 100 cases were randomly selected from the burn department of a hospital from January 2012 to December 2014 and the defects of the first page were analyzed. Results A total of 24 defects were detected, of which 15 were defects in surgical operation, 6 were wrong in main operation and 3 were missed in operation. Conclusion lack of understanding, lack of knowledge, insufficient attention, poor quality control is the cause of the first page of burn operation medical records filled with defects. Awareness raising, training enhancement and quality control will help to improve the quality of medical record homepage.