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目的规范病案首页填写,提高HQMS网络直报信息质量。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。本文分析了目前信息网络直报病案首页填写的质量。结果 12367份病案中,有缺陷的病案首页累计2819例,占22.80%。缺陷包括基本情况16.99%、出院诊断填写20.01%、手术、操作填写21.67%、疾病和手术操作分类8.90%、三级医师签名不及时28.80%、其他错误3.62%。结论采取对临床医生、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、增设病案质量控制岗位等措施,可以提高病历首页质量。
Purpose To standardize the first page of the medical record and improve the quality of the direct report information of the HQMS network. Methods According to the International Classification of Diseases tenth edition (ICD-10) of the main diagnosis fill in the requirements and selection principles. According to “Guangxi medical record writing norms” standard for home page quality analysis, according to HQMS report the first page of data requirements. This paper analyzes the current information network direct filing the first page of the quality of medical records. Results Among the 12,367 medical records, there were 2819 cases of defective medical records, accounting for 22.80%. Defects included 16.99% of the basic conditions, 20.01% of discharged diagnoses, 21.67% of surgeries and operations, 8.90% of diseases and surgical procedures, 28.80% of third-level physicians’ signatures, and 3.62% of other errors. Conclusion It is possible to improve the quality of the first page of the medical record by taking standardized job training for clinicians, medical record coders and other related personnel, setting up a first-line quality control system for hospital-level and second-level medical records, and setting up additional quality control records.