提高病案首页填写质量相关经验

目的 探讨改进病案首页填写质量的有效方法。方法 随机抽取我院2002年1月至2005年1月住院病案500份，作为甲组，随机抽取2005年2月至2008年2月住院病案500份，作为乙组。将病案首页填写内容分成8项，统计两组病案错填的病案数，结果用SPSS11．5统计软件进行分析。结果 治疗结果填错、手术操作填错、出院诊断不明确错误发生率乙组低于甲组，差异有统计学意义（P〈0．05）。结论 医院加大对病案首页填写质量考核力度可提高病案首页质量。

Related Experience of Improving the waiting Quality of the Front sheet of medical record

Objectives to investigate effective methods for improving writing quality of front sheet of medical record. Methods select randomly 500 medical record from January 2002 to January 2005 in our hospital as group A, from February 2005 to February 2008 as group B; divide filling - in content of front sheet of medical record into 8 items; to count the number of wrong filling-in medical record for 2 groups and analyze its results by using statistic software SPSS11.5. Results Group B is less than Group A at the rate of wrong filling- in treatment outcome, operation and surgery and unclear discharged diagnose. The differences have its statistic meaning （ P 〈 0. 05）. Conclusions In order to improve the quality of front sheet of medical record, hospital should reinforce assessment of filling - in quality of it.