病案首页录入对统计的影响

• 作 者: 冷文玉 蒋志伟 刘召平 方瑞燕
• 机 构: 济南军区总医院信息科,济南军区总医院信息科,济南军区总医院信息科,济南军区总医院信息科,
• 出 处: 中国病案
• 发表日期: 2007年05期
• 关键词: 病案首页 统计

目的通过纠正病案首页填写错误,理顺病案首页与统计的关系,提高统计数据的准确性。方法对病案统计在病案首页录入过程中存在的主要问题及对统计数据的影响进行相关调查分析提出对策。结果发现住院登记处、临床医生的首页填写、护士工作站的信息录入等存在诸多问题,并提出加强科室沟通管理和质量监督检查、提高病案人员业务素质等措施。结论经过病案统计室与临床各个工作站及时周密协调沟通,纠正错误,使得统计数据具有真实性、科学性、准确性。

Objective To improve the accuracy of statistical data by correcting mistakes on the front page of medical records and straightening out the relationship between the first page of medical records and statistics. [Methods] The countermeasures were made on the major problems existing in the process of the medical records entering the home record and the impact on the statistical data. As a result, it found that many problems existed in the inpatient admissions office, the clinician’s home page filling, and the information input of nurses’ workstations. They also proposed measures such as strengthening department communication management and quality supervision and inspection, and improving the quality of medical personnel. Conclusion Through careful and coordinated communication between the medical record office and clinical workstations in a timely manner, the errors are corrected, making the statistical data authentic, scientific, and accurate.