【摘要】 目的探索提高病案首页信息质量的方法。方法通过全样本统计,并结合随机抽样方法,分析病案首页信息完整性和准确性填写情况。结果在2986份病案首页调查中,56个必填项中11个项目出现了空项,有13.8%的出生日期、7.9%的医疗付费方式、41.9%的年龄在5岁以下的职业、22.0%的切口类型和23.2%的愈合等级出现填写错误,94.7%的手术名称与标准不符,在相符的手术名称中有51.3%的手术级别不符,在抽查的448份病案中,有17.6%的病案首页医疗信息与病历书写不符。结论充分利用信息化手段,减少病案首页信息人为错误;强化培训,建立检查机制,促进病案首页信息质量的提高;综合治理,是保证病案首页信息质量的根本。更多还原

【Abstract】 Objective To explore the methods to improve the quality of the front sheet of Medical Record information. Methods Through the statistics of the whole samples and using the method of random sampling, analyzing the integrity and accuracy of the front sheet of medical record information. Results In the 2986 samples, 11 fields appeared empty in the 56 required fields. 13.8% of the date of birth, 7.9% of the medical payment method, 41.9% of the profession of the aged under five,22.0% of the surgical incision, and 23.2% of the level of healing fill out the mistakes. 94.7% of the operation names were not according with the standard. 51.3% of the operation level was discrepancy. In the 448 medical records, 17.6% of the front sheet of medical record information were not according with medical records written. Conclusions Through making full use of information technology to reduce human error. Intensive training and establish inspection mechanism to improve the information quality. Comprehensive treatment is essential to ensure the quality of the front sheet of medical record.更多还原