新版病案首页填写存在的问题及改进措施

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。

Problems and Improvements of Filling Problems in the New Version of the Medical Record Front-page

According to a document(2011) No.84 issued by Medical Administrative Department of the Ministry of Health named Filling Instruction about FrontPage Items of Hospitalization Medical Records,and Reminding Instruction about FrontPage Items of Hospitalization Medical Records,this paper analyzes filling quality of medical records front-page turning out lots of filling defects which include basic information of patients and medical information,such as place of birth,telephone,zip code,ID number of patient information or using ’unknown’ instead,work unit and address,household address and etc;the problems of leaving out signature of medical staffs are serious in medical information;filling about external causes of injury and poison and pathological diagnosis is not standard,which affect the accuracy of disease coding.There are more problems of the new items of the new version of the medical record,such as the filling in ’autopsy for death patients’ is 2(No) for patients without death;the phenomenon of leaving out filling for neonatal age and birth weight,level of surgery,pathology number happens all the time.Therefore,in order to improve filling quality of medical record front-page,we need to strengthen training,quality control and to fully apply informationization management technology for further perfecting medical record management and laying a foundation for pre-payment system reform.