论文部分内容阅读
目的分析病案信息管理中的难点及影响因素,确保病案信息的完整性和科学性。方法前瞻性与回顾性调查分析我院2008年1月-2008年12月反复出错的病案首页项目。结果转科科别(转科时间)、门(急)诊医生(工号)、手术操作记录、产科分娩婴儿记录、肿瘤专科病人治疗记录、费用是错误率较高的填写项目也是病案首页信息管理中的难点。概念不清及病案首页不科学设计是错填、漏填的主要原因。结论提高对病案信息重要性的认识,科学设计病案首页,加强病案信息管理知识培训,严把病案信息录入关,健全监督检查制度是提高病案首页填写质量的有效措施。
Objective To analyze the difficulties and influencing factors in the medical record information management and ensure the integrity and scientificness of the medical record information. Methods Prospective and retrospective analysis of our hospital from January 2008 -2008 December recurrent case of illness home page project. The results of the transfer subjects Section (transfer subjects), the door (emergency) doctor (ID), surgical records, obstetric childbirth records, treatment of cancer specialist records, the cost is a high error rate entry is the record page information Difficulties in management. The concept is unclear and medical records Home unscientific design is the main reason for the wrong fill, fill in. Conclusion To improve the understanding of the importance of medical record information, to design the medical record home page scientifically and to strengthen the knowledge management of medical record information management, to strictly record the medical record information and to improve the supervision and inspection system is an effective measure to improve the quality of medical record homepage.