2050份新冠肺炎专病救治医院住院病案首页质量分析

目的 通过分析新冠肺炎(COVID-19)专病救治医院2050份住院病案首页质量,为管理提供参考.方法 收集某新冠专病救治医院2020年2月27日、3月12日、3月20日、4月9日4次出院病案首页检查结果,对住院病案首页的完整性和准确性特征进行分析.结果 4次共检查2050份出院病案,首页质量平均扣分为(0.69±0....

Front Pages Quality Analysis of 2,050 Inpatient Medical Records of COVID-19 Special Diseases Treatment Hospitals

Objectives By analyzing the quality of front pages of 2,050 inpatient medical records of COVID-19 special diseases treatment hospitals, this paper provided reference for management. Methods 2050 front pages of medical records of a COVID-19 special diseases treatment hospital were examined on February 27th, March 12th, March 20th and April 9th, 2020. Results A total of 2050 discharged medical records were examined, and the average score was(0.69±0.49). The proportion of defective cases in each time were 62.07%, 44.57%, 32.37% and 69.27% respectively. The incidence of defective in first time and forth time was significantly higher than that in second time and third time(χ²=33.574,P=0.000). The ischemic fluid test was the defect prone to occur in each exam. The highest diagnostic basis, the lack of items on the attachment page of the front pages, and the lack of infusion response records were found in 3 exams. Conclusions The integrity and accuracy of the front pages of the medical record was an important basis for the retrieval and extraction of the treatment information of COVID-19 special diseases treatment hospital. The stage inspection of the front pages of the discharged medical record could timely understand the deficiencies in the medical process.