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目的通过对2012版病案首页在信息系统中的设置的研究和临床填写首页的情况分析,探讨控制病案首页填写质量的方法。方法从信息系统中导出2012年10月份医生填写的病案首页所有项目,以Excel形式进行分类统计。结果病案首页有21个项目存在空项,最高空项率为62.86%,身份证号填写错误率为7.3%,在728个手术操作名称中,8.8%个手术操作名称级别填写不统一。结论强化培训是病案首页质量控制的基础,完善信息化是病案首页质量控制的重要手段,加强监控是病案首页质量控制的保证。
Objective To explore the ways to control the quality of the first page of the medical records by studying the settings of the 2012 first page of medical records in the information system and analyzing the first page of clinical settings. Methods All items on the first page of the medical record filled in by doctors in October 2012 were derived from the information system and classified by means of Excel. Results There were 21 items in the first page of medical records, the highest empty item rate was 62.86%, and the incorrect ID card number was 7.3%. Among the 728 surgeries, 8.8% of the surnames were not filled in. Conclusions Intensive training is the basis of the quality control of the first page of the medical records. Improving the informatization is an important means of quality control of the first page of the medical records, and strengthening the monitoring is the guarantee of the quality control of the first page of the medical record.