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目的掌握2012版病案首页入院病情填写情况,探索提高入院病情填写质量的方法。方法对某院2012年1月-3月6844份出院病案首页中的主要诊断入院病情项目进行归类汇总,检查分析。结果 6844份出院病案首页中主要诊断入院病情为临床明确诊断的5852例,占85.5%,填写错误率0.22%;临床未确定诊断的664例,占9.7%,填写错误率9.79%;情况不明的143例,占2.1%,填写错误率5.59%;入院时无,入院后新发生的185例,占2.7%,填写错误率47.03%,是入院病情填写准确性最低的一项。结论加强对临床医师关于入院病情选项含义及填写要求的讲解,要求医师重视问诊与沟通,利用计算机进行入院病情的监测,减少填写错误,提高填报正确率。
Objective To master the 2012 version of the first page home admission condition, to explore ways to improve the quality of admission to fill in. Methods A total of 6,844 hospital discharge cases in a hospital from January to March in 2012 were collected and analyzed. Results The main diagnosis and admission of 6,844 cases were 5852 clinically diagnosed cases (85.5%), with an error rate of 0.22%. 664 cases were undetermined and accounted for 9.7% of the total, and the error rate was 9.79%. The unknown status 143 cases, accounting for 2.1%, fill in the error rate of 5.59%; admission no, 185 cases occurred after admission, accounting for 2.7%, fill in the error rate of 47.03%, is the lowest admission accuracy of a. CONCLUSIONS To enhance the explanations of clinicians about the meaning and requirements of admission options, requiring doctors to pay attention to interrogation and communication, using computers to monitor hospitalization, reduce errors and improve the accuracy of reporting.