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根据卫医政发〔2011〕84号《住院病案首页部分项目填写说明》及《住院病案首页项目修订说明》,对我院病案首页填写质量进行分析,发现首页填写缺陷较多,涵盖了患者基本信息及医疗信息,如患者基本信息中出生地、电话、邮编、身份证号等漏填或用“不详”代替,工作单位及地址、户口地址等填写缺陷;医疗信息中医护人员漏签名问题较严重。另外损伤、中毒的外部原因及病理诊断常填写不规范,影响疾病编码的准确性。新版病案首页新增项目也存在较多问题,如未死亡的患者“死亡患者尸检”处仍填写为2(否),新生儿年龄与出生体重、手术级别、病理号等漏填现象时有发生。为提高病案首页填写质量,需加强培训,强化质量控制,充分利用信息化管理技术,以进一步完善病案管理,为预付费制改革做好铺垫工作。
According to the “Weidongzhengfa [2011] No. 84” inpatient medical record first part of the project to fill in description “and” inpatient medical record homepage project revision instructions “, to our hospital medical record homepage fill quality analysis and found that the home page fill more defects, covering the basic Information and medical information, such as the birthplace, telephone number, postal code, ID number, etc. in the basic information of the patient, such as missing or filled in with ”unknown", workplace and address, account address, etc .; The problem is more serious. In addition, damage, poisoning, external causes and pathological diagnosis often fill in non-standard, affecting the accuracy of disease coding. There are also more problems with the new item in the new homepage of the new case. For example, if the patient is not dead, the autopsy of the deceased patient is still filled in with 2 (no), neonatal age and birth weight, operation grade and pathological number Have happened. In order to improve the quality of the first page of the medical record, it is necessary to strengthen training, strengthen quality control and make full use of information management techniques so as to further improve the medical record management and pave the way for prepaid fee system reform.