【作者】 肖晓兰； 贺海平； 赵杰； 古菊珍； 覃丽丽； 陆凤海； 陆伟；

【Author】 XiaoXiaolan;He Haiping;Zhao Jie;Gu Juzhen;Qin Lili;Lu Fenghai;Lu Wei;Information Center,Guangxi Cancer Hospital;

【机构】 广西肿瘤医院信息中心病案室；

【摘要】 目的规范病案首页填写、确保国际疾病编码的准确性及加强病案首页质控审核,提高HQMS网络直报信息质量,与确保医院评审评价数据的真实性。方法依据国际疾病分类第十版(ICD-10)的疾病主要诊断填写要求及选择原则。按照《广西病历书写规范》标准进行病案首页质量分析,根据HQMS的上报病案首页数据的要求。本文分析了目前我院信息网络直报病案首页填写存在的缺陷问题。结果病案首页填写存在着患者信息采集不及时、不完整、不准确;主要诊断及出院情况选择错误;手术切口书写不符规定:手术、操作填写不规范;以及疾病和手术操作分类错误等问题。结论应针对我院病案首页存在的质量问题进行分析并提出对临床医生、病案编码人员等相关人员进行规范化岗位培训,建立院、科两级病案首页质量监控体系,并增设病案质量控制岗位等措施.更多还原

【Abstract】 To standard medical record front sheet filled out,ensure the accuracy of international disease coding,and attempt to strengthen the audit quality of control.To improve the quality of a network for information about the Hospital Quality Monitoring System(HQMS),and guarantee the authenticity of the data from the hospital review system.Objective This study attempts to analysis of the current defects existed in our HQMS.Classification for the diseases was according to the tenth edition International classification of diseases(ICD-10).Selection principle for primary diagnosis was according to the "Guangxi medical record writing standard".Front sheet of the medical record was according to the requirements of the HQMS.Results Insufficient of patients’ information collected mainly included the data was not completed,inaccurate,and was not in time.Information for primary diagnosis,discharge from the hospital,surgical incision,types of the operation,and classification of disease were wrong.Besides,it was not standard for operation filled in.Conclusion We should settle the shortages of the HQMS via training clinicians,staff working for medical record coding.Furthermore,two levels of monitoring system for hospital-to-clinical department was urgent to build,and it is helpful to take measures such as adding positions for medical record quality.更多还原