CAJ | 학술논문

目的通过对2012版病案首页在信息系统中的设置的研究和临床填写首页的情况分析,探讨控制病案首页填写质量的方法.方法从信息系统中导出2012年10月份医生填写的病案首页所有项目,以 Excel形式进行分类统计.结果病案首页有21个项目存在空项,最高空项率为62.86%,身份证号填写错误率为7.3%,在728个手术操作名称中,8.8%个手术操作名称级别填写不统一.结论强化培训是病案首页质量控制的基础,完善信息化是病案首页质量控制的重要手段,加强监控是病案首页质量控制的保证.
목적통과대2012판병안수혈재신식계통중적설치적연구화림상전사수혈적정황분석,탐토공제병안수혈전사질량적방법.방법종신식계통중도출2012년10월빈의생전사적병안수혈소유항목,이 Excel형식진행분류통계.결과병안수혈유21개항목존재공항,최고공항솔위62.86%,신빈증호전사착오솔위7.3%,재728개수술조작명칭중,8.8%개수술조작명칭급별전사불통일.결론강화배훈시병안수혈질량공제적기출,완선신식화시병안수혈질량공제적중요수단,가강감공시병안수혈질량공제적보증.
@@@@Objective To research the setting of the front sheet of medical records 2012 version in the information system and analyze the fil ing of clinicians ,so as to discuss measures to control the quality of medical record fil ing .Methods Exporting al the items of front sheet of medical records in October 2012 ,making classified statistics with EXCELL .Results There are 21 empty entries in the front sheet and the highest rate is 62 .86% .The error rate of ID number fil ing is 7 .3% ,and 8 .8% of the 728 surgical operation grade fil ings are not uniform .Conclusions Intensive training ,improving information construction and strengthening monitoring are the base ,methods and guarantee for the front sheet quality control .