病案首页质量管理简

目的量化评估病案首页的质量，进一步提高病案首页的质量。方法按2012年卫计委颁发的《病案首页填写说明的若干规定》，设立20个质控点，制作并使用《病案首页检查评分表》对某院同日出院的病案首页167份进行质控。结果病案首页填写的合格率95．2％；患者基本信息缺漏的比率最多，占29．9％；诊断符合情况错填率达到12．6％；病理号、损伤中毒的原因及过敏药物漏填率10．8％。结论通过加强学习考核、限期整改、建立循环把关制度、督促各项检查单的及时归档工作、及时反馈的措施循环可以提高病案首页的质量。

Quality Management of the Front Sheet of Medical Record

Objective To quantitatively assess the quality of the front sheet of medical record, and further improve the quality of the front sheet of medical record. Methods Setting up 20 quality control points according to The front sheet of medical record completing certain rules which is issued by health development planning commission in 2012. Product and use the front sheet of medical record mark sheet to check 167 front sheets of medical records on the same day. Results The percent of pass of Fill in is 95.2%; Patients basic information incomplete accounted for 29.9%; Conformance with the diagnostic errors accounted for 12.6%; Pathology number, the reason of damage and poisoning and drug allergy accounted for 10.8%. Conclusion Strengthening the learning assessment, rectification within a time limit, setting up the loop control system, supervise and urge the archives work of checklist, timely feedback loop can improve the quality of the front sheet of medical record.