肾内科电子病历首页填写过程中常见问题与防范.docxVIP

肾内科电子病历首页填写过程中常见问 题与防范 贾晓燕周宏久陈丽娟李东敏 广东医科大学附属医院病案室广东医科大学附属医 院肾内科 摘要： 目的研究某院肾内科电子病历首页填写过程中的常见问题，总结防范措施，提 高病案首页质量;方法 随机选取2016年1月-2016年12月某院肾内科终末病案 2000例，根据原卫生部下发的《病历书写基本规范》国家卫计委《住院病历质 量考核评分标准》，评价其首页填写过程中的常见问题，进行统计分析。结果某 院肾内科电子病历首页常见缺陷包括:基本信息填写不完整、不规范220例，占 11.00%;主要诊断选择错误28例，占1.40%;诊断书写不规范166例，占8.30%; 病理诊断及院内感染填写不完整或漏填26例，占1. 30%;手术操作名称不规范62 例，占3. 10%;切口愈合等级填写不规范或漏填32例，占1.60%;离院方式选择错 误86例，占4. 30%。结论病案首页填写存在许多问题，通过加强病案首页书写 的规范性、准确性和可靠性管理，可提高病案首页书写质量，全而提升医疗管理 水平。 关键词： 电子病历;病案首页;病案管理; 收稿日期：2017-07-15 Common Problems and Countermeasures in the Filling of Front Pages of Electronic Medical Records in Nephrology Medicine Department Tia Xiaoyan Zhou Hongjiu Chen Li juan Li Dongmin D e p artment ofMe dical Records, The Affiliated Hospital of Guangdong Medical University; Abstract： the quality of the front pages of medical of medical records from our hospitai from were cnrolled in this study， and checked health medical record writing basicObjectives To explore common problems of the front pages of medical records in the department of nephrology of our hospital, and summary countermeasures and improve records. Methods 2000 cases Jemuary to December in 2016 contrast to the ministry of specifications and quality standard of inpatient medical records, and analyze and count all kinds of defects. Resu Its The comm on defec ts of front pages of electronic medical record in our hospital including: the basic infooieition was not completc and standardized (220 cases, 11. 00%)、 primary diagnostic selection error (28 cases, 1. 40%) and diagnostic writing were not standardized (166 cases, 8. 30%) , the pathological diagnosis and the hospital infection were not complete or not filled (26 cases, 1. 30%) , operation name was not standardized or not filled (62 cases, 3. 10%) and wound healing grade was not standardized or not filled (32 cases, 1. 60%) , leave hospital mode selection error (86 cases, 4. the quality of the front pages of medical of medical records from our hospitai from were cn