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目的通过对我院2010年病案首页缺陷情况进行分析并提出对策,为医院的病案质量管理和医疗安全提供参考。方法根据卫生部《病历书写基本规范》,对24,136份出院病案进行质量监控。结果病案首页缺陷主要以诊断信息和手术信息漏填、错填的比例最高。结论提高病案质量的关键是病案首页的质量,而对病案首页质量的把关,则需要医务人员努力提高专业技能和责任感。
Objective To analyze and propose the countermeasures for the defects of the first page of medical records in our hospital in 2010 and provide references for the medical records quality management and medical safety of the hospitals. Methods According to the “Basic Norms of Medical Records Writing” issued by the Ministry of Public Health, the quality of 24,136 discharged medical records was monitored. Results The first page of the medical record was mainly filled with the missing diagnostic information and the surgical information, the highest proportion was the wrongly filled. Conclusion The key to improving the quality of medical record is the quality of the front page of the medical record, while checking the quality of the front page of the medical record requires the medical staff to work hard to improve their professional skills and responsibility.