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目的分析病案首页质量缺陷原因,提出改进措施并实施管理。方法对2007出院病案进行回顾性检查,针对存在的主要问题进行原因分析,制定改进措施并组织实施,实施管理后对2008年出院病案首页进行监督检查,评价整改措施的有效性。结果2007年17 582份出院病案首页缺陷率45.7%,通过规范管理2008年19 610份首页缺陷率降至12.1%。结论加强管理病案首页的质量管理,不但提高了病案的整体质量,而且可以提高医疗统计信息的完整性和准确性。
Objective To analyze the causes of the quality defects in the first page of the medical record, propose the improvement measures and implement the management. Methods Retrospective examination of the discharged medical records in 2007 was carried out. The reasons for the main problems were analyzed, the improvement measures were formulated and implemented. After the implementation of management, the first page of the discharged medical records was supervised and evaluated in 2008 to evaluate the effectiveness of the corrective measures. Results In 17 582 cases, the first page defect rate of discharge cases was 45.7% in 2007, and the number of first page defects in 19 610 cases in 2008 was reduced to 12.1% through standard management. Conclusion Strengthening the quality management of the home page of medical records not only improves the overall quality of the medical records but also improves the completeness and accuracy of medical statistics.