病案中患者更名现象分析

目的:分析病案中患者更名的现象,为医院病案管理提供参考。方法:对病案中患者更名人次、更名原因、住院科室、出院情况等信息进行分类汇总,对比分析。结果:2010年—2012年入院人次为4 867人次,更名人次为76人次,更名人次占入院人次百分比为1.56%,患者更名为同音字占60%以上。结论:防患于未然,加强医院管理,尤其是更名的规范化,避免不必要的纠纷,大力推广实名制就医。

Analysis of patients renamed phenomenon in medical records

Objective ： To analyze the phenomenon of patients renamed of medical records in order to keep better manage- ment for it. Methods ： To classify and collect data of patient renamed number, renamed reason, hospitalized department and dis- charge information, then to compare and analyze. Resuhs ：From 2010 to 2012, the inpatient number and the renamed number of patient is 4 867 and 76 respectivly. The ratio of patient renamed is 1.56%. And the patients for homophone renamed are more than 60%. Conclusion：It is necessary to strengthen the hospital management and normalize the renamed system to avoid unde- sirable troubles. And it is important to strongly encourage the real - name hospitalization.