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目的对重症产科患者住院病案首页主要诊断选择错误因素的分析,以提高病案首页填写质量。方法回顾性检索2015年北京地区两家医院产科重症患者病案资料,找出住院病案首页主要诊断选择错误病案,通过列举典型错误分析错误产生原因。结果检索重症产科患者196例,主要诊断选择错误23例。主要错误原因集中在两个方面:将呼吸循环衰竭这种疾病的终末期情况作为主要诊断;病因诊断已经能够包括一般的临床表现,未选择病因诊断作为主要诊断。结论重症产科患者病案首页主要诊断选择错误发生率较高,产生错误的原因相对集中,通过培训相关专业知识,可以提高选择的正确率。
Objective To analyze the main diagnostic errors in the main medical records of patients with severe obstetric patients, and to improve the quality of the first page of medical records. Methods The data of medical records of critically ill obstetric patients in two hospitals in Beijing in 2015 were retrospectively searched to find the main medical records of inpatient medical records and to find out the causes of the errors by enumerating the typical mistakes. Results A total of 196 cases of critically ill obstetric patients were retrieved, with 23 cases of major diagnostic errors. The main causes of errors are focused on two aspects: the end-stage condition of the respiratory cycle failure as the primary diagnosis; etiological diagnosis has been able to include the general clinical manifestations, etiology diagnosis was not selected as the main diagnosis. Conclusion The main diagnosis of critically ill obstetric patients on the first page of a higher incidence of misdiagnosis, the reasons for the error is relatively concentrated, by training the relevant expertise, can improve the accuracy of the choice.