病历初检缺陷分析及干预对策

孙珊梅,李萌,吴丹

(解放军总医院病案管理科,北京100853)

[摘要]目的通过统计初检病历缺陷，分析缺陷构成比及产生原因，为医院行政管理部门制定对症措施提供科学依据。方法回顾2011年3月—2012年2月初检病历回收整理发现的缺陷进行统计分析，采取相应的干预措施。结果2013年3月—2014年2月缺陷词条为1 765条，缺陷率较前下降9.76%。结论干预措施的执行，有效加强初检病历的源头管理，提高终末病历质量，保障医疗质量与安全，为建立结构化电子病历提供基础数据，推进病案信息化管理进程，具有重大的管理意义。

[关键词]病历初检缺陷分析;干预;前瞻性管理意义

[中图分类号]R 197.32[文献标识码]A

[作者简介]孙珊梅，女，硕士在读，主管技师;电话:13621305566

Defect Analysis and Intervention Measures on First Check of Medical Records

SUN Shan-mei, LI Meng, WU Dan(Section of Medical Records Management, General Hospital of PLA, Beijing100853)

Abstract[]ObjectiveTo analyze the composition and causes of defect of first check medical record by statistical methods, so as to provide a scientific basis for hospital administration departments to develop policies and measures. MethodsReviewing the defects of medical records from March 2011 to early February 2012, and analyzing the section of cause the defect. After this, some appropriate interventions were put forward. ResultThe sum of defects is 1 765 counting from March 2013 to Feb 2014. The defect rate reduced 9.76% than before. ConclusionThe intervention measures enhanced the source management of first medical records, improved the quality of final medical records, ensured the safety and quality of medical treatment. It has great management significance on providing fundamental data for structured electronic medical record, which would push the progress of information management for medical record.

[Key words]defect analysis for first check of medical record; intervention; perspective management significance

Hosp Admin J Chin PLA，2015，22(9)：844-845.

病历是对疾病诊断治疗的如实记录，是医学科学的档案资料，对医院的医疗、教学、科研和管理具有重要的使用价值，是医疗保险及法律纠纷的重要凭证及证据。病案的管理质量反映医院的医疗技术和医疗管理水平。通过病案质量监控有利于及时发现并杜绝医疗行为的不安全隐患，所以病案质量管理是医疗质量管理的重要环节[1]。我国各医院的病案管理部门或科室不能做到对终末病历质检率100%，初检病历的缺陷成为导致终末病历缺陷主要原因，从而使病历再利用失去真实性、准确性，造成价值损失。本文通过分析初检病历缺陷发生的主观和客观原因，有针对性地采取相应措施，完善管理制度，确保病历质量及其利用价值的实现，提高管理水平，为病案信息化管理和持续改进积累经验。……