【摘要】 目的 研究某三级医院住院病案首页主要诊断填写情况及其影响因素，为提高主要诊断填写正确率提供参考。方法 采用方便抽样方法，选取2023年1月1日-12月31日39 127例住院患者。通过回顾病案，对住院病案首页主要诊断填写情况进行判断。运用单因素分析和多因素Logistic回归分析,探讨影响住院病案首页主要诊断填写的因素。结果 住院病案首页主要诊断填写正确率为90.9%，主要错误原因为主要诊断笼统（55.4%），其次为主要诊断选择错误（44.1%）。入院途径（急诊：OR=0.796；其他途径：OR=0.130）、入院病情(临床未确定：OR=0.554 )、RW分组（0.50-0.79:OR=3.165;1.20-1.99:OR=1.663;2.00-4.99:OR=6.432；≥5.00:OR=6.772）、转科情况（OR=1.334）和主治医师性别（OR=0.887）是主要诊断填写正确率的影响因素（P<0.05）。结论 医院主要诊断填写正确率整体水平良好，应加强临床医师的专项培训，提升医院病案质量控制能力，尤其加强对门诊入院、有入院病情、病情复杂程度较高患者住院病案首页的重点质控，加强转科患者管理与交接，完善信息系统建设。更多还原

【Abstract】 Objectives To study the filling situation of the main diagnoses on the front page of inpatient medical records in a tertiary hospital and its influencing factors, and provide a reference for improving the accuracy rate of filling in the main diagnoses. Methods A convenience sampling method was used to choose 39127 patients from January 1st to December 31st, 2023. Assessing the main diagnosis filling situation on the front page of medical records by reviewing medical records. Both single factor analysis and Multifactorial Logistic regression analysis were used to explore the influencing factors of the main diagnosis filling situation. Results A total of 39127 inpatient medical records were included in this study, the accuracy rate of filling in the main diagnosis on the front page of medical records was 90.9%. The main cause of error was the general filling of the main diagnosis(55.4%), followed by the error of the main diagnosis selection(44.1%). Admission routes(emergency: OR=0.796;other ways: OR=0.130), admission conditions(clinically undetermined: OR=0.554), groups of Relative Weight(0.50-0.79: OR=3.165; 1.20-1.99: OR=1.663; 2.00-4.99: OR=6.432; ≥5.00: OR=6.772), transfer scenarios(OR=1.334) and sex of attending physician(OR=0.887) were the main factors which influenced the accuracy rate of filling in the main diagnosis(P<0.05). Conclusions The overall accuracy rate of filling in the main diagnosis in the hospital was satisfactory, yet significant variations in these indicators were evident across different admission routes, admission conditions, groups of Relative Weight, transfer scenarios and sex of attending physician. Consequently, it was imperative to reinforce specialized training for clinicians, elevate the hospital’s capability in medical record quality control, especially strengthen the key quality control of the front page of inpatient medical records for patients admitted through outpatient clinics, patients with admission conditions, and patients with high complexity of conditions, bolster the management and transition of patients undergoing transfers, and refine the construction of information systems.更多还原