【摘要】 目的对某院新版住院病案首页的质量进行监测,分析管理措施的效果。方法根据该院制定的《新版住院病案首页考核评分表》,对2013年4月~2014年3月全院各病区的出院病案首页进行随机检查并考核,分析病案首页不合格率的变化趋势及存在的问题,及时采取相应的管理措施。结果从2013年4月~2014年3月度病案首页不合格率呈现下降趋势,其中2014年1-3月的不合格率最低,仅6.2%。9000份出院病案首页的缺陷构成情况为:漏填缺陷中构成比最高的为"医师签名",占16.5%;错填缺陷中构成比最高的为"出院诊断",占10.8%。结论通过分析病案首页漏填缺陷及错填缺陷的原因,采取的包括规范病案首页的填写及质控流程、加强培训、充分利用病案管理信息系统等管理措施能显著的提高病案首页的完整性及准确性。更多还原

【Abstract】 Objective To monitor the quality of home pages in the new edition of medical records, and analyze the effects of the management measures in our hospital. Methods To conduct an inspection and assessment on the home pages in the discharged medical records of all the inpatients areas from April 2013 to March 2014 according to the "Assessment Rating Scale of Home Pages in the New Edition of Medical Records" formulated by the hospital, analyze the variation tendency of reject ratio of medical records home pages as well as the problems existing, and adopt relevant management measures. Results The reject ratio of medical records home pages was decreasing from the second quarter in 2013 to the first quarter in 2014, in which the lowest reject ratio was the first quarter in 2014, only 6.2%. In the constitution of the defects of 9000 medical record home pages, the highest constitution ratio of missing filling defects was "physician’s signature", which was 16.5%. The highest constitution ratio of mistaken filling defects was "discharged diagnosis", which was 10.8%. Conclusions Through analyzing the reasons of missing or mistaken filling defects in the home pages of medical records, we should adopt management measures such as standardizing the filling and quality controlling process of the home pages, strengthening training and taking full advantages of the medical records information management system, thus could we improve the integrity and accuracy of home pages in the medical records.更多还原