从病案首页疾病诊断填写看医院感染报告
|
摘要
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 filling status of related hospital infection diagnosis in the front pages of medical record, investigate the situation of failing report and find out reasons, so as to manage quality improvement continuously. Methods To conduct inspection on all the front pages of medical records in a Class A and tertiary Hospital from 2012 to 2014, find out the cases belong to hospital infection in the diseases diagnosis in front pages of medical records, and search failing report cases according to the existing standard. Results Only 166 hospital infection cases were correctly filled among all the 456 cases reported. Meanwhile, only 166 cases with correct infection diseases diagnosis in the front pages were reported among all the 438 cases. Conclusions There were nonstandard and inconsistent phenomenon in writing and reporting of the hospital infection disease. We should adopt the standard name of hospital infection diseases and strengthen the training and inspection of writing the front pages, so as to promote the filling of front pages, hospital infection supervising and report work more standard.
Objective To analyze the filling status of related hospital infection diagnosis in the front pages of medical record, investigate the situation of failing report and find out reasons, so as to manage quality improvement continuously. Methods To conduct inspection on all the front pages of medical records in a Class A and tertiary Hospital from 2012 to 2014, find out the cases belong to hospital infection in the diseases diagnosis in front pages of medical records, and search failing report cases according to the existing standard. Results Only 166 hospital infection cases were correctly filled among all the 456 cases reported. Meanwhile, only 166 cases with correct infection diseases diagnosis in the front pages were reported among all the 438 cases. Conclusions There were nonstandard and inconsistent phenomenon in writing and reporting of the hospital infection disease. We should adopt the standard name of hospital infection diseases and strengthen the training and inspection of writing the front pages, so as to promote the filling of front pages, hospital infection supervising and report work more standard.
引文
[1]中华人民共和国卫生部.卫生部关于修订住院病案首页的通知[EB/OL].[2011-11-02].http://moh.gov.cn/mo-hyzs/s3585/201111/53492.shtml.
[2]赵勇,张建勇,崔霞.加强医院感染管理的工作方法探讨[J].中华医院感染学杂志,2010,20(6):836.
[3]黄碧波,赵小佳,李建军.4397份新版病案首页入院病情归类分析[J].中国病案,2013,14(2):21-23.
[4]肖玲,李析茜,贾庚,等.医院感染存在的问题与改进措施[J].中华医院感染学杂志,2010,20(20):3179.
[5]冯乐玲,金波娜,孙雪芬.医院感染报告中存在问题的分析及预防措施[J].中华医院感染学杂志,2012,22(4):789-790.
[2]赵勇,张建勇,崔霞.加强医院感染管理的工作方法探讨[J].中华医院感染学杂志,2010,20(6):836.
[3]黄碧波,赵小佳,李建军.4397份新版病案首页入院病情归类分析[J].中国病案,2013,14(2):21-23.
[4]肖玲,李析茜,贾庚,等.医院感染存在的问题与改进措施[J].中华医院感染学杂志,2010,20(20):3179.
[5]冯乐玲,金波娜,孙雪芬.医院感染报告中存在问题的分析及预防措施[J].中华医院感染学杂志,2012,22(4):789-790.