【摘要】 目的分析主要诊断入院病情填写缺陷,为病案首页质量管理提供参考。方法某院自2020年5月1日起加强病案首页主要诊断入院病情质控。抽取加强质控前2020年4月1日-2020年4月30日3320份病案首页与加强质控后2020年5月1日-2020年9月30日19 014份病案首页。比较质控前后主要诊断入院病情填写错误率。结果加强质控前后主要诊断入院病情错填率分别为2.56%、1.39%,差异有统计学意义(χ~2=25.23,P<0.001)。主要诊断及入院病情影响主要诊断选择共25份。结论加强病案首页质控后主要诊断入院病情错填率明显下降,部分临床医师对入院病情的定义仍存在模糊不清以及未认真填写的问题,需加强质控及培训,进一步调高填写正确率。更多还原

【Abstract】 Objectives To analyze the admission condition of the primary diagnosis filling defects through quality inspection of the front page of inpatient medical records, in order to improve the accuracy of medical statistics, and provide support for the DRGs payment system. Methods Since May 1 st, 2020, the admission condition of the primary diagnosis filling quality control was strengthened. Senior members of the medical record specifies in the encoding were appointed to control the quality of the admission condition of the primary diagnosis, scored the results of the quality control, reported and feed backed the results to the clinician.3320 front page of inpatient medical records in the hospital from Apr 1 st, 2020 to Apr 30 th, 2020 and 19014 front page of inpatient medical records from May 1 st to Sep 30 th, 2020 were collected. Compare the error rates of the primary diagnosis admission conditions before and after quality control with SPSS22.0 software, and analyze the filling condition of the primary diagnosis admission conditions and its influence on the selection of the primary diagnosis after strengthening quality control.Results The error rates of primary diagnosis admission condition before and after quality control was 2.56%,1.39%, the difference was statistically significant(χ~2=25.23,P<0.001). After quality control, a total of 264 cases of primary diagnosis admission condition were filled incorrectly. Primary diagnosis admission condition incorrectly filled with 1 "Yes", 2 "clinically undetermined",3 "unknown condition",4 "no" were168(63.64%),56(21.21%),26(9.85%),14(5.30%) separately. In addition, for 25 cases, the choice of the primary diagnosis were affected by the Primary diagnosis admission condition. Conclusions After strengthening quality control, the error rates of the admission condition of the primary diagnosis decreased obviously. However, some clinicians were not very clear about the definition of the admission condition, and filled in it not carefully. The quality control of medical record and training of clinical doctors should be strengthened so as to reduce the errors and improve the correct rate.更多还原