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目的:探讨病理检查申请与诊断报告单存在的问题及相关影响因素。方法:回顾性分析宁海县第一医院病理科2011年1月~2013年12月共23451份病理检查申请及诊断报告单,分析总结其存在问题及相关影响因素。结果:23451份病理检查申请及诊断报告单中,住院病例12743份,门诊病例10042份。不合格病理检查申请单共610份(占2.6%),主要影响因素为缺失临床诊断、缺失病史与缺失申请医生。不合格诊断报告单56份(占0.24%),主要影响因素为标本大体与镜下扫描过于简单。结论:不合格的主要影响因素为缺失临床诊断,医院各科室之间需要注重协同合作,进而提升病理检查申请与诊断报告单的质量。
Objective: To explore the problems existing in application and diagnosis report of pathological examination and related influential factors. Methods: A total of 23,451 pathological examination applications and diagnostic reports were collected from Department of Pathology, the First Hospital of Ninghai from January 2011 to December 2013, and the existing problems and related influencing factors were analyzed and summarized. Results: Among 23451 pathological examination applications and diagnosis reports, 12,743 inpatients and 10,042 outpatients were found. A total of 610 applications (2.6%) failed to pass the pathological examination. The main influencing factors were the absence of clinical diagnosis, the absence of medical history and the absence of a doctor. 56 failed report (0.24%), the main influencing factors were the general and microscopic scanning of the specimen was too simple. Conclusion: The main influencing factors of failure are clinical diagnosis of absence, and all the departments in the hospital need to pay attention to the cooperation and cooperation so as to improve the quality of pathological examination application and diagnosis report form.