【摘要】 目的了解某省病案首页填写缺陷情况,分析原因,提出改进措施,为下一步顺利开展DRGs工作打下基础。方法从某省卫生统计直报系统数据库中抽取52家三级医院2017年病案首页数据,从缺项、误填、填写规范、逻辑错误和质量评分方面对住院病案首页进行分类统计分析。结果抽取的三级医院2 331 180份病案首页中,项目填报完整率为96.03%,缺陷率为3.97%,其中患者住院过程信息缺陷率最高,为7.42%,其中入院科别缺陷严重,缺陷率达50.64%,且三级非甲非乙等医院缺陷率要高于三级甲等和三级乙等医院。某省病案首页数据平均分为91.75分,优秀率为16.37%,合格率为95.15%。结论某省三级医院病案首页缺陷的主要原因在于医务人员重视度不够和质控监管不到位,病案首页质量有待提高,需要提高医务人员对病案信息重要性的认识,并利用信息化手段进行病案首页质量控制。更多还原

【Abstract】 Objective To understand the defects of the first page of a province’s medical records, analyze the reasons, and propose improvement measures to lay the foundation for the smooth development of DRGs. Methods The data of the 2017 medical records of 52 tertiary hospitals were extracted from the database of the provincial health statistics direct reporting system. The classification and statistical analysis of the inpatient medical records was carried out from the aspects of missing items, incorrect filling, filling in norms, logic errors and quality scores.Results In the first page of the 2331180 medical records of the tertiary hospitals, the completion rate of the home page was 96.03%, and the defect rate was 3.97%. The defect rate of the hospitalization process was the highest in the homepage content, which was 7.42%. The admissions were seriously defective, the defect rate is 50.64%, and the defect rate of the third-level unrated hospital is higher than that of the top three and three hospitals. The average data of the first page of a province’s medical records is 91.75 points, the home page excellent rate is 16.37%, and the pass rate is 95.15%. Conclusion The main reason for the defect in the front page of the third-grade hospital in a province is that the medical staff is not paying enough attention and the quality control is not in place. The quality of the homepage needs to be improved. It is necessary to improve the medical staff’s understanding of the importance of the medical record information, and use the information technology to conduct homepage quality control.更多还原