CAJ | 학술논문

目的：探讨妇产科住院病案首页的主要诊断和主要手术不一致的原因，研究如何合理选择妇产科病案首页的主要诊断，使其与主要手术操作相一致。方法提取2014年妇产科15652份出院病案，其中11588份含有各种妇产科手术操作，了解主要诊断与主要手术操作的填写情况。结果11588份住院病案的主要诊断和主要手术操作符合率77.5%，8981份主要诊断与主要手术相匹配，1043份属于部分不一致，1564份属于完全不一致。1043份部分不符合的病例中，妇科所占比例82.55%；产科仅占比17.45%。而1564份完全不符合的病例中，产科所占比例83.63%；妇科占比16.37%。结论主要诊断选择需要根据患者疾病的临床诊疗过程和主要诊断选择原则等多方面因素综合判断，主要手术操作应与主要诊断相对应。
목적：탐토부산과주원병안수혈적주요진단화주요수술불일치적원인，연구여하합리선택부산과병안수혈적주요진단，사기여주요수술조작상일치。방법제취2014년부산과15652빈출원병안，기중11588빈함유각충부산과수술조작，료해주요진단여주요수술조작적전사정황。결과11588빈주원병안적주요진단화주요수술조작부합솔77.5%，8981빈주요진단여주요수술상필배，1043빈속우부분불일치，1564빈속우완전불일치。1043빈부분불부합적병례중，부과소점비례82.55%；산과부점비17.45%。이1564빈완전불부합적병례중，산과소점비례83.63%；부과점비16.37%。결론주요진단선택수요근거환자질병적림상진료과정화주요진단선택원칙등다방면인소종합판단，주요수술조작응여주요진단상대응。
Objective To explore the reason on inconsistence of major diagnosis and major operation on the front sheet of Medical Record. It aims to find out how to select major diagnosis for Obstetrics reasonably so that they can be matched together.Method 15 652 cases of gynecology-obstetric medical records in 2014 were selected as research objects, 11 588 cases including all types of obstetric operation. We try to investigate the general picture of major diagnosis and major operation consistence.Result Among 11 588 medical records, total coincidence rate of major diagnosis and major operation was 77.5%, 8981 cases were completely matching,1043 cases were partly matching,1564 cases were totally inconsistent. In 1043 cases, Gynecology(82.55%), Obstetrics(17.45%); however among 1564 cases, Obstetrics (83.63%), Gynecology(16.37%). Conclusion Multiple factors should be taken account when selecting major diagnosis. Major operation should be carefully judged by major diagnosis.