浅析网络管理模式下病案首页质量控制

计算机信息管理中，病案首页的信息是医院系统的主要内容。病案首页的信息反映了医院收治病人的医疗工作情况，是上级卫生部门进行卫生经费拨款、评价医院质量的重要依据。在网络管理模式下，建立新的病案首页质量控制，实现网络管理模式下病案首页信息的及时、完整、准确、真实性，是医院病案管理必须解决的问题。本文对网络管理模式下病案首页中存在的问题进行了分析，对提高网络条件下病案质量提出了具体看法。     

网络条件下病案首页填写缺陷分析及对策

病案是基础医疗工作的基础,病案首页是病案主要内容的摘要和综合反映。随着电子计算机在医院中广泛应用,医院许多部门如住院处、收费处、病案室、医院统计室,病案质量检查室和电子计算机中心都是利用病案首页进行医院管理和医疗质量管理,为医疗、保健、教学和科研提供各种信息服务。病案首页信息是医院管理最基础、最重要的信息,它直接反映医院医疗工作的病人信息、诊断信息、治疗信息、医嘱信息、手术信息和医疗费用信息等,是各级卫生机构领导对医院医疗工作宏观决策、上级卫生部门进行卫生经费拨款、评价医院医疗工作质量的重要依据,也是处理医疗纠纷的法律凭证。     

网络条件下病案首页录入质量缺陷分析与对策探讨

网络条件下的病案首页信息可以实现一处录入，多处共享，信息的采集点就是信息的发生点。入院处是病案首页信息录入的第一站，由于工作粗疏，致使病案首页前部分的错误信息记录带入整个病历之中，严重影响病案资料的准确性和完整性，也给日后查询、检索工作带来诸多不便。现将我们对某医院病案首页录入中存在的缺陷原因进行分析，并提出改进意见。     

6770例病案首页质量分析

病案首页是住院病人信息资料的核心部分，它包括了病人的基本情况、门诊医疗情况、住院诊断情况及住院医疗经费等内容，是病案内容的浓缩。病案首页是管理、科研、教学、医疗、统计最重要的信息基础．通过网络系统实现病案首页资源共享和信息交换，迅速准确地为医院各项工作提供优质服务。因此，加强病案首页的质量管理，促进病案质量的提高是一项重要工作。为进一步提高病历质量，我们对6770份住院病历首页进行了统计分析，报告如下。     

3068份病案首页的问题分析及控制

病案质量管理是全面医疗质量管理的基础 ,病案首页又是对病案的主要内容和重要信息的高度概括。作者通过分析病案首页填写中存在的问题 ,力求指导临床医师正确填写病案首页 ,以确保填写的内容准确、真实方能为医院科研、医疗管理提供更好的信息资源     

我院病案首页填写存在的问题及质量控制

病案是患者诊疗、救治过程的原始资料。病案首页是整份病案当中内容最集中、最核心的部分。它所提供的信息不仅服务于临床诊治、医疗管理、科研及统计 ,并在社会保险、事故认定以及医疗纠纷中承担法律依据。因此 ,正确填写病案首页 ,不仅关系到病案资料的准确性、完整性 ,也直接影响病案的医疗价值和社会价值。1　病案首页填写方面存在的主要问题1 .1　主要诊断选择错误1 .1 .1　个别医生填写诊断时 ,习惯给定一个大的范围 ,然后写出具体部位及性质。其结果造成编码、统计时将笼统的诊断作为第一诊断 ,影响统计的准确性。例 :心脏病、风湿性…     

网络环境下病案信息管理存在的问题及对策

信息时代,医院病案管理已成为医院现代化管理的重要组成部分,病案信息质量直接影响着医疗信息质量。我院运行医院信息系统(HIS)后,网络环境下的病案信息管理与先前的单机管理有了很大差异,管理中出现了许多新问题。分析存在问题,提出有效的解决方法是确保病案信息管理质量的重要途径。     

Noncardiogenic pulmonary edema as the first manifestation of pheochromocytoma: a case report

We report here a case of pheochromocytoma presenting with noncardiogenic pulmonary edema, which is an unusual first manifestation of pheochromocytoma. Chest radiograph showed diffuse consolitaion and ground-glass opacity on both lungs. Neither pleural effusion nor cardiomegaly was present. High-resolution computed tomography (HRCT) showed widespread ground-glass opacity with fine intralobular reticular opacity (so-called "crazy-paving" appearance) and consolidation in a strikingly dependent distribution. The areas of ground-glass opacity and consolidation were sharply marginated by interlobular septa, showing a geographic appearance. The pulmonary edema and dyspnea resolved over three days without cardioactive or diuretic treatment. Noncardiogenic pulmonary edema is an unusual first manifestation of pheochromocytoma. It is important to recognize this unusual manifestation in the emergency situation.     

因阴囊肿大发现布-加综合征1例

患者男,40岁。因阴囊肿大10余天到我院就诊。检查前暴露会阴部发现阴囊肿大十分明显（约正常阴囊大小5倍以上）,行彩超检查后发现阴囊壁水肿增厚（图1）,厚度约8 mm。双侧睾丸、附睾、精索未见明显异常。阴囊肿大的常见原因有：鞘膜积液、睾丸炎、附睾炎、     

Avulsion fracture of peroneus longus at the first metatarsal insertion: a case report

Reports of isolated avulsion fracture at the planter lateral base of the first metatarsal without injury of the tarsometatarsal joint are very rare. A 24 year old man sustained an avulsion fracture at the plantar lateral base of the first metatarsal. Normal alignment of metatarsal bones and tarsometatarsal joint was maintained. In this paper, we describe internal fixation of the displaced fragment using x ray and minimally invasive surgery with good results.     

Factors influencing the absorbed dose in intraoral radiography

OBJECTIVES: The aim of the present study was to find out whether it was more effective to achieve a dose reduction in intraoral radiography with an increase in the tube potential setting (and a decrease of milliampere seconds) by an additional attenuation of the X-ray beam behind the film plane or by the use of digital radiography. A second aim was to find out if there were differences between the integral doses determined by two different detectors and two different phantoms. METHODS: The X-ray attenuation in this in vitro study was carried out using additional lead foils from the dental film packet fixed behind the film plane and with a metal film holder. The dose measurements were performed with two semiconductor detectors (Quart, Diados). Patient simulation was achieved by the Alderson phantom or by the use of a filter (6Al+0.8Cu). The absorbed doses were calculated by integrating an exponential function between the entrance dose and the body exit dose. In addition, organ doses were measured and the effective dose was determined according to the Implementation of the 1990 Recommendations of the ICRP (ICRP-60). RESULTS: The increase in tube potential levels did not provide a substantial reduction of the absorbed dose (90 kVp instead of 60 kVp: reduction to 92.4%), only a reduction of the entrance dose (by 30% to 35% at 90 kVp compared with 60 kVp). The use of three lead foils behind the film plane instead of one resulted in a 14.0% reduction of the absorbed dose (60 kVp); the use of a metal film holder resulted in a 27.8% reduction (60 kVp). When tube potential settings were increased, the dose reduction decreased. The absorbed dose was reduced to 52% when a storage phosphor plate was used instead of a film (60 kVp). It was possible to determine the amount of dose reduction with both the calculated absorbed dose and the effective doses. The integral doses obtained from the Alderson phantom showed values 5% higher than those obtained by the filter (r(2)=96.7%). For the comparison of the integral doses, the measurements performed with Quart had values higher by a factor of 1.139 than those performed with Diados. CONCLUSIONS: Instead of increasing the tube voltage or using additional lead foils or metal film holders, a substantial dose reduction is provided by digital radiography or more sensitive films while a low tube potential level is maintained and the milliampere seconds setting is reduced.     

Factors influencing the exercise behaviour of patients

The sports physician faces major practical problems in stimulating the activity of sedentary patients, and also ensuring their subsequent adherence to a prescribed exercise regimen. Both individual and society bear some responsibility for poor exercise compliance. Patients are most likely to persist with programmes which are well-adapted to their physical, physiological, psychological and socioeconomic characteristics. The quality of leadership is also an important variable. Open-ended and structured questionnaires suggest that motivations to exercise include the improvement of health, the development of fitness, the control of bodyweight as well as an improvement in personal appearance, socialising, and simply a wish to 'feel better'. The main perceived reason why people 'drop out' of formal exercise classes is through lack of time, although often the individuals making this complaint appear to have substantial free time. Personality characteristics of the adherent depend on the type of programme that is offered and the degree of social support that is provided; extraversion, a high self-esteem and self-motivation are common findings. Modelling of exercise behaviour has drawn upon the concepts of Skinner, Becker and most recently Fishbein. Beliefs and their evaluation seem more influential than subjective norms, although exercise behaviour is also heavily influenced by past experience of physical activity. Programmes should be designed to maximise external reinforcement of the exercise habit until the early discomforts of training are overcome, and the patient discovers the internal rewards of a more active lifestyle.     

The first magnetic resonance imaging-detected case of bilateral seminal vesicle duplication: An illustrative case report

Given the increasing use of prostate magnetic resonance imaging (MRI) for imaging suspected cancer and male infertility, understanding imaging features of congenital anomalies of the seminal vesicles (SVs) is of clinical importance. This case presents the first MRI-detected case of bilateral SV duplication with an isolated right SV cyst in the absence of other congenital genitourinary anomalies. In addition to illustrating imaging features of this rare anomaly, this case provides an overview of the role of MRI in providing accurate diagnosis and guiding management options of the most common SV anomalies.     

心肌摄取^131I—MIBG的影响因素

为了解影响心肌摄取１３１Ｉ间位碘代苄胍（ＭＩＢＧ）的因素，研究了鼠心肌对不同比活度ＭＩＢＧ和使用部分血管活性药物后的摄取及清除，同时对１６例正常人和４９例心肌疾病、４例非心肌疾病患者用不同比活度１３１ＩＭＩＢＧ行心肌显像。结果：鼠心肌在延迟相（４小时以后）对高比活度的ＭＩＢＧ摄取明显大于低比活度的ＭＩＢＧ，并得到临床初步研究证实；在不同时相，血管活性药物心得安（２４小时）、多巴胺（１小时）和多巴酚丁胺（４小时）均对鼠心肌清除ＭＩＢＧ有影响。因此，ＭＩＢＧ比活度、心血管活性药物和部分非心肌疾病均能影响心肌对ＭＩＢＧ的摄取和清除，在应用中应排除上述干扰。