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目的通过病案首页手术相关信息分析某院手术分级管理现状,为建立手术分级信息化管理系统提供依据。方法收集2016年1月1日-2016年6月30日5个外科科室手术病例第一术式,对病案首页手术级别、手术名称、术者资质及手术分级构成修正前后进行分析。结果手术级别、手术名称及术者资质缺陷率分别为36.74%、12.99%和1.74%;手术分级缺陷中以级别降低为主,占85.28%;三、四级手术占比由修正前50.42%提高到69.09%;各级手术中由高级别专业技术职务的医师完成手术占比相对较高,分别为48.82%、64.51%、84.76%、94.27%。结论医院应尽快建立手术分级信息化管理系统,实现手术名称与手术分级自动关联,提高手术分级数据的准确性;综合各级医师的专业特长、手术技术水平等情况限定医师手术权限并实行动态管理,避免高级别专业技术职务的医师垄断手术。
Objective To analyze the status of surgical grading management in a hospital through information related to the first page of medical records and provide evidence for establishing a grading information management system. Methods The first surgical procedure of five surgical departments was collected from January 1, 2016 to June 30, 2016. The first surgical procedure, the name of the operation, the qualifications of the surgeon and the composition of the operation were analyzed before and after revision. Results The grade of operation, the name of operation and the qualification rate of the surgeon were 36.74%, 12.99% and 1.74%, respectively. The grade was mainly decreased in the grade of operation, accounting for 85.28%. The proportion of grade 3 and 4 operation increased from 50.42% before revision To 69.09%. The proportion of operations performed by doctors in high-level professional and technical positions at all levels of surgery was relatively high, accounting for 48.82%, 64.51%, 84.76% and 94.27% respectively. Conclusions The hospital should set up a surgical grading information management system as soon as possible so as to realize the automatic correlation between the surgical name and surgical grading and to improve the accuracy of the surgical grading data. The physician’s professional competence and technical level are all qualified to limit the physician’s surgical authority and carry out dynamic management , To avoid high-level professional and technical positions of the monopoly of surgery.