主要诊断与主要手术操作选择及填写缺陷分析

目的规范病案首页的填写,提高病案首页主要诊断与手术操作填写质量。方法提取2012年2万份病案,其中疾病诊断与手术操作各1万份,了解主要诊断与主要手术操作的填写情况。结果 1万份住院病案的首页中主要诊断填写的缺陷率为12.5%;主要手术操作填写的缺陷率为21.6%。主要问题是名称书写不规范:包括英文缩写、笼统的名称、分解书写、主要诊断与主要手术操作的选择错误等。结论加强对临床医师进行ICD-10知识的普及、健全监督检查制度、加强病案管理人员把关作用等措施是提高病案首页质量的有效方法。

Defects Analysis of the Principal Diagnosis and Operations

Objective To standardize the writing of home pages of medical records and improve the writing quality of the principal diagnosis and operations. Method 20000 cases of medical records in 2012 were analyzed in our hospital, half of which were principal diagnosis and the others were operations, to investigate the writing situation of principal diagnosis and operations. Results The defect rate of principal diagnosis was 12.5 % in the home pages of 10000 cases of medical records while that of the operation was 21.6%. The main problems were not standardized writing of titles, including English abbreviation, general titles, decompose writing, wrong- ly choosing of principal diagnosis and operations and so on. Conclusions To strengthen the popularize of ICD - 10 knowledge among clinical doctors, complete supervision and inspection system and enhance the control function of medical records managers are all effec- tive measures to improve the quality of the home pages of medical records.