中国病案
中國病案
중국병안
Chinese Medical Record
2015年
10期
25-27
,共3页
倪俊%许献荣%顾海峰%陈瑞彩
倪俊%許獻榮%顧海峰%陳瑞綵
예준%허헌영%고해봉%진서채
烧伤%病案首页%手术操作名称%ICD-9-CM-3
燒傷%病案首頁%手術操作名稱%ICD-9-CM-3
소상%병안수혈%수술조작명칭%ICD-9-CM-3
Burn%Front Sheet of medical records%Operation name%ICD-9-CM-3
目的：分析烧伤科病案首页手术名称填写缺陷原因，探索提高质量方法。方法以病案首页填写规范和ICD-9-CM-3分类编码原则为标准，对某院烧伤科2012年1月至2014年12月病案随机检查100份，分析病案首页手术名称填写缺陷。结果共检查出缺陷病案24份，其中手术操作名称书写缺陷15份，主要手术操作选择错误6份，漏记手术操作名称3份。结论认识不足、知识缺乏、重视不够、质控不力是烧伤科病案首页手术操作名称填写存在缺陷原因。提高认识、加强培训、强化质控有助于提高病案首页质量。
目的：分析燒傷科病案首頁手術名稱填寫缺陷原因，探索提高質量方法。方法以病案首頁填寫規範和ICD-9-CM-3分類編碼原則為標準，對某院燒傷科2012年1月至2014年12月病案隨機檢查100份，分析病案首頁手術名稱填寫缺陷。結果共檢查齣缺陷病案24份，其中手術操作名稱書寫缺陷15份，主要手術操作選擇錯誤6份，漏記手術操作名稱3份。結論認識不足、知識缺乏、重視不夠、質控不力是燒傷科病案首頁手術操作名稱填寫存在缺陷原因。提高認識、加彊培訓、彊化質控有助于提高病案首頁質量。
목적：분석소상과병안수혈수술명칭전사결함원인，탐색제고질량방법。방법이병안수혈전사규범화ICD-9-CM-3분류편마원칙위표준，대모원소상과2012년1월지2014년12월병안수궤검사100빈，분석병안수혈수술명칭전사결함。결과공검사출결함병안24빈，기중수술조작명칭서사결함15빈，주요수술조작선택착오6빈，루기수술조작명칭3빈。결론인식불족、지식결핍、중시불구、질공불력시소상과병안수혈수술조작명칭전사존재결함원인。제고인식、가강배훈、강화질공유조우제고병안수혈질량。
ObjectiveTo monitor the quality of operation name writing in front sheet of burn surgical medical records and analyze the methods to improve the quality.Methods 100 cases of discharged burn surgical medical records in our hospital from January 2012 to December 2014 were inspected randomly, and conducted retrospective analysis on the operation name in front of those medical records. Results 24 cases were found out defects in operation name. The defects involved in deficiencies of the operation name(15 cases), wrong selection of principle operations name(6 cases), and unrecorded operation procedure name(3 cases).Conclusion The quality problems existing sheet of burn surgical medical records. Recognize the importance of ICD-9-CM-3 coding, master the principles of operation procedure classification and strengthen quality control could improve the quality of front sheet of burn surgical medical records.
