CAJ | 학술논문

目的：降低住院患者基本信息录入错误率。方法收集2012年1月至2013年12月，福州市某三级医院病案室在册登记的“住院患者基本信息修改记录本”、《住院患者基本信息修改申请表》和病历等资料，统计基本信息错误的类型，分析发生错误的原因。并在采取干预措施实施前后一年，观察住院患者基本信息修改率变化情况。结果跟踪数据采集过程的质量持续改进情况，信息修改率从2012年度的1．18％降低到2013年度的0．78％，干预收效明显。结论干预措施的执行，有效减少住院患者基本信息发生错误的概率。并结合医院实际，提出系列持续改进措施，收到成效。
목적：강저주원환자기본신식록입착오솔。방법수집2012년1월지2013년12월，복주시모삼급의원병안실재책등기적“주원환자기본신식수개기록본”、《주원환자기본신식수개신청표》화병력등자료，통계기본신식착오적류형，분석발생착오적원인。병재채취간예조시실시전후일년，관찰주원환자기본신식수개솔변화정황。결과근종수거채집과정적질량지속개진정황，신식수개솔종2012년도적1．18％강저도2013년도적0．78％，간예수효명현。결론간예조시적집행，유효감소주원환자기본신식발생착오적개솔。병결합의원실제，제출계렬지속개진조시，수도성효。
Objective To reduce the occurrence of information entry mistakes of inpatients .Method The causes for wrong patient information were collected from “correcting medical records and applications of correcting wrong information of inpatients”from January 2012 to December 2013.Then the effect was analyzed by comparing be-fore and after taking related intervening measures .Results The occurrence of patient's wrong information reduced from 1.18%in 2012 to 0.78%in 2013.Conclusion The intervening of false data and strategies for correction pa-tient information were of significance in reducing the frequency of changing personal data .