CAJ | 학술논문

目的：通过对近两年某院出院患者的入院病情进行统计，分析入院病情的填写和统计过程中存在的问题，并针对填写规范和报表统一问题提出改进措施。方法对某院2013年-2014年全院出院病例的入院病情进行统计、汇总，采用Excel 2007和SPSS19.0进行数据整理和统计分析。结果2013年和2014年主要诊断中入院病情4（无）所占比例分别为0.18%和0.21%；所有诊断中入院病情4（无）的病例数所占比例分别高达3.21%和4.15%；入院病情“无”的误判率较高，2013年和2014年误判率分别高达40.73%和32.59%。结论住院病案首页入院病情填写质量不容乐观，入院病情4（无）的错判率较高，同时入院病情的统计亟需规范和统一，入院病情4（无）应统计所有诊断。
목적：통과대근량년모원출원환자적입원병정진행통계，분석입원병정적전사화통계과정중존재적문제，병침대전사규범화보표통일문제제출개진조시。방법대모원2013년-2014년전원출원병례적입원병정진행통계、회총，채용Excel 2007화SPSS19.0진행수거정리화통계분석。결과2013년화2014년주요진단중입원병정4（무）소점비례분별위0.18%화0.21%；소유진단중입원병정4（무）적병례수소점비례분별고체3.21%화4.15%；입원병정“무”적오판솔교고，2013년화2014년오판솔분별고체40.73%화32.59%。결론주원병안수혈입원병정전사질량불용악관，입원병정4（무）적착판솔교고，동시입원병정적통계극수규범화통일，입원병정4（무）응통계소유진단。
Objectives To analyze the problems existing in the filling of admission condition and the process of statistics through an analysis on the admission condition of discharged patients in the past two years, and put forward some improvement measures aimed at the filling standard and the common problems of report forms. Methods To conduct statistical analysis and summary on the admission condition of all the inpatients from 2013 to 2014 of a hospital, and make data reduction and statistical analysis with the application of Excel 2007 and SPSS19.0. Results In 2013, the 4th admission condition accounted for 0.18%among the main diagnosis, while it accounted for 0.21%in 2014. Among all the diagnosis, the 4th admission condition took a proportion of 3.21%and 4.15%in 2013 and in 2014 respectively. But 40.73%of the 4th admission condition were wrong judged in 2013, and 32.59%of them were wrong judged in 2014. Conclusions The filling quality of home pages in the medical records was not optimistic, the misjudgment rate was very high in filling the 4th admission condition. Meanwhile, statistics of admission condition needed specification and unity, all diagnoses need to be taken into account.