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目的分析病案首页疾病诊断中有关医院感染诊断的填写现状,调查医院感染漏报情况,查找原因,以实施持续质量改进。方法对某三级医院2012年-2014年所有出院病案首页进行核查,找出病案首页疾病诊断中属于医院感染的病例,依照标准查找漏报情况。结果科室手工报告医院感染的病例456例中在病案首页中正确填写的仅166例;而病案首页中438例感染诊断病例仅手工报告医院感染166例。结论医院感染报告与病案首页填写存在不一致、不规范现象。应该采取规范医院感染诊断和加强病案首页填写的培训、督查等措施,促使病案首页填写、医院感染监测和报告工作更规范。
Objective To analyze the current situation of filling the diagnosis of nosocomial infections in the diagnosis of diseases, investigate the omission of nosocomial infections and find out the reasons for the continuous improvement of quality. Methods Check the first page of all discharged cases in a tertiary hospital from 2012 to 2014 and find out the cases of nosocomial infections in the first case of disease diagnosis and find the omissions according to the standard. Results Of the 456 reported cases of nosocomial infections, only 166 cases were correctly filled out in the first page of the case record. Of the 438 cases diagnosed on the first page of the case record, only 166 cases of nosocomial infection were reported by hand. Conclusion There are inconsistencies and irregularities in filling in the first page of the hospital infection report and medical record. Should be standardized nosocomial infection diagnosis and strengthen the home page to fill in the training of medical records, supervision and other measures to promote the home page of medical records, hospital infection monitoring and reporting more standardized.