某医院2016年住院病案首页离院方式填写缺陷情况分析
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摘要
[目的]分析某医院2016年住院病案首页离院方式填写缺陷情况.[方法]收集某医院2016年度的住院病案首页信息47 562份,对离院方式填写缺陷情况进行统计分析.[结果]47 562份住院病案首页中离院方式填写有缺陷的为496份,占1.04%,其中非医嘱离院填写缺陷最多见,为435份,占总缺陷的87.70%.[结论]某医院2016年住院病案首页离院方式填写缺陷情况较普遍,应重视离院方式填写规范和质量.
OBJECTIVE To analyze the filling in defects of leaving hospital way on the home pages of medical records of a hospital in 2016.METHODS A total of 47 562 home pages of medical records of a hospital were collected,filling in defects of leaving hospital way were statistically analyzed.RESULTS496 of the 47 562 medical records were found to have the filling in defects of leaving hospital way on the home pages,accounting for 1.04%,filling in defects of non-medical orders was more common,the number was435,accounting for 87.70% of the all medical records with defects.CONCLUSIONIt was common for the filling in defects of leaving hospital way on the home pages of medical records of a hospital in 2016,so the norm and quality of filling in should be paid attention to.
OBJECTIVE To analyze the filling in defects of leaving hospital way on the home pages of medical records of a hospital in 2016.METHODS A total of 47 562 home pages of medical records of a hospital were collected,filling in defects of leaving hospital way were statistically analyzed.RESULTS496 of the 47 562 medical records were found to have the filling in defects of leaving hospital way on the home pages,accounting for 1.04%,filling in defects of non-medical orders was more common,the number was435,accounting for 87.70% of the all medical records with defects.CONCLUSIONIt was common for the filling in defects of leaving hospital way on the home pages of medical records of a hospital in 2016,so the norm and quality of filling in should be paid attention to.
引文
[1]李医华,崔延姬.延边地区某医院病案填写错误情况分析[J].延边大学医学学报,2015,38(4):340-341.
[2]朱晓荣.住院病案首页离院方式填写质量分析及对策[J].中国病案,2017,18(8):6-8.
[3]崔延姬,全振喜,方今女,等.延边地区某医院外科住院病案首页填写缺陷情况分析[J].延边大学医学学报,2016,39(4):275-277
[4]阮鹤瑞,刘晓明,金疆山,等.病案首页填写缺陷分析及对策建议[J].中国病案,2015,16(2):20-24.
[5]李文峰,曹慕慧.病案首页质量管理[J].中国病案,2014,15(1):30-31.
[2]朱晓荣.住院病案首页离院方式填写质量分析及对策[J].中国病案,2017,18(8):6-8.
[3]崔延姬,全振喜,方今女,等.延边地区某医院外科住院病案首页填写缺陷情况分析[J].延边大学医学学报,2016,39(4):275-277
[4]阮鹤瑞,刘晓明,金疆山,等.病案首页填写缺陷分析及对策建议[J].中国病案,2015,16(2):20-24.
[5]李文峰,曹慕慧.病案首页质量管理[J].中国病案,2014,15(1):30-31.