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Analysis of the First Page of 2,236 Medical Records with Writing Defects and Relevant Countermeasures 2236份病案首页书写缺陷分析及对策
Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.932073
Daqiao Zhu, Wenjun Zhang, Lijiang Yong, Shaoyong Huang
AbstractObjective. To analyze the writing defects in the first page of medical records and propose improvement measures. Methods. The Quality Examination Score Scale of First Page of Medical Records was developed according to the requirements of the Instructions for Filling Some Items on the First Page of Medical Records issued by the former Ministry of Health; the medical records from January to February 2014 of our hospital were randomly sampled; 2,236 records were obtained and the completeness of the first page of each record was analyzed. Results. The proportion of the medical records with no defects in the first page was 49.41% (1,105/2,236); the defect rate was 50.58% (1,131/2,236); the qualified rate of the first page of the medical records was 94.49% (2,113/2,236); and the unqualified rate was 5.50% (123/2,236); there were many problems in the first page of medical records such as incompleteness, mistakes, and non-standard writing. Conclusion. The problem of poor quality in the first page of medic...
AbstractObjective。分析病案首页的书写缺陷,提出改进措施。方法。《病案首页质量检查分值表》是根据原卫生部《病案首页部分填表须知》的要求制定的;随机抽取我院2014年1 - 2月的病历;获得了2236条记录,并分析了每条记录第一页的完整性。结果。病历首页无缺陷的比例为49.41% (1,105/2,236);不良率为50.58% (1,131/2,236);病案首页合格率为94.49% (2,113/2,236);不合格率为5.50% (123/ 2236);病案首页存在着不完整、错误、书写不规范等问题。结论。医学报告第一页的质量问题…
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引用次数: 1
Effect of Systematic Follow-up Home Visits on the Healthy Behavior of Patients after Interventional Treatment of Arteriosclerosis Obliterans 系统随访家访对动脉硬化闭塞症介入治疗后患者健康行为的影响
Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.935990
S. Tian
AbstractObjective. To discuss the effect of systematic follow-up home visits on the healthy behavior of patients after interventional treatment of arteriosclerosis obliterans (ASO). Methods. A total of 100 patients discharged from hospital after the interventional treatment of ASO were randomly divided into an observation group and a control group, each group having 50 members. The members of each group were given professional discharge instructions; the control group received follow-up telephone calls, while the observation group had systematic follow-up home visits which were recorded in detail; a comparison and an analysis of the healthy behaviors of the members in the two groups were made after one year of follow-up. Results. The healthy behavior of the observation group members was obviously better than that of the control group members. (There were significant differences in life attitudes, disease knowledge, awareness of risk factors, enthusiasm for exercise, and timely medicine use) The X2 values ...
AbstractObjective。探讨系统随访家访对动脉硬化闭塞症(ASO)介入治疗后患者健康行为的影响。方法。将100例ASO介入治疗后出院的患者随机分为观察组和对照组,每组50人。每个组的成员都得到了专业的出院指导;对照组随访电话,观察组系统随访家访,详细记录;随访1年后,对两组成员的健康行为进行比较分析。结果。观察组成员的健康行为明显优于对照组成员。(在生活态度、疾病知识、危险因素认知、运动热情、及时用药等方面存在显著差异)
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引用次数: 0
Comparative Analysis of Medical Record Management Between Hospitals in China and Australia 中澳两国医院病案管理比较分析
Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.935992
Ying Xu
AbstractThe medical record management departments of hospitals in China and Australia are different in terms of establishment of the department, division of functions, working contents, information utilization, staff and professional education and so on. The factors that contribute to the differences include management philosophy, payment mechanism, health care system, and professional education facilities. Nowadays, China is undergoing an in-depth reform of the health care system, as the promotion and application of reform measures such as the implementation of clinical pathways and payment systems related to disease diagnosis are underway. The work of medical record management will be fortified and the cooperation between China and Australia will also increase.
摘要中澳两国医院病案管理部门在科室设置、职能分工、工作内容、信息利用、人员配备和专业教育等方面存在差异。造成差异的因素包括管理理念、支付机制、医疗保健制度和专业教育设施。当前,中国正在进行深入的医疗卫生体制改革,与疾病诊断相关的临床路径、支付制度等改革措施正在推广应用。加强病案管理工作,加强中澳合作。
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引用次数: 0
Application Study of the HIS-Based Death Case Report Module 基于his的死亡病例报告模块的应用研究
Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.932076
Xue Bai, Aimin Liu
AbstractThe Notice of BJHB about Carrying Out the Pilot R&D of the Death Case Report Module, Jing Wei Ban Zi [2013] No. 78 document of the Beijing Health Bureau (BJHB), has stipulated that five hospitals, including the Peking Union Medical College Hospital (PUMCH), will carry out the pilot R&D of the death case report module based on the hospital information system (HIS). The informatized death case reporting system was designed on the principles of simplifying processes, improving efficiency and guaranteeing security, and its functions include auto-capturing certificate numbers and basic information, logic verification, electronic signature and statistics. The promotion and utilization of the electronic death case report module should also combine with the characteristics of each medical institution, as well as the communication and acceptance of related administrations such as the National Centers for Disease Control and Prevention, the Ministry of Civil Affairs and public security organizations.
摘要《北京市卫生局关于开展死亡病例报告模块试点研发工作的通知》京卫办字[2013]78号文规定,北京协和医院等5家医院开展基于医院信息系统(HIS)的死亡病例报告模块试点研发工作。基于简化流程、提高效率、保障安全的原则,设计了信息化死亡病例报告系统,实现了自动获取证号和基本信息、逻辑验证、电子签名、统计等功能。电子死亡病例报告模块的推广和利用还应结合各医疗机构的特点,以及国家疾病预防控制中心、民政部、公安机关等相关行政部门的沟通和接受情况。
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引用次数: 0
Analysis of Problems in 996 Defective Hospital Admission Records and Relevant Countermeasures 996份不良住院记录问题分析及对策
Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.932071
Mingxia Yu, Hongwei Zhang, Yiyang Deng, Ya-min Liu
AbstractObjective. To improve the quality of medical records and develop countermeasures by analyzing the problems existing in the hospital admission records of the medical records of inpatients. Methods. To conduct a statistical analysis on 996 cases of defective hospital admission records in the whole year of 2013, according to the Basic Criterion of Documentation of the Medical Record launched by the Ministry of Health and the Writing Quality Checklist of Medical Records (Final) of Inpatients issued by the Beijing Health Bureau, which includes twelve items: general condition, chief complaint, history of present illness, physical examination and so on. Results. Of the defective hospital admission records, the records without the doctor's signature account for 42.37%, the records without the final diagnosis or with an incomplete final diagnosis account for 40.46%, and defects in surgical medical records are significantly more than those of the department of internal medicine. Conclusion. Through the spec...
AbstractObjective。通过分析住院病人病历中住院病历存在的问题,提高病历质量并制定对策。方法。根据卫生部发布的《病案文件编制基本规范》和北京市卫生局发布的《住院患者病案编写质量检查表(定稿)》,对2013年全年996例有缺陷的住院记录进行统计分析,包括一般情况、主诉、病史、体格检查等12个项目。结果。在有缺陷的住院记录中,无医生签名的记录占42.37%,无最终诊断或最终诊断不完整的记录占40.46%,外科病历的缺陷明显多于内科病历。结论。通过规范…
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引用次数: 0
Management of Unplanned Resurgery 计划外手术的处理
Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.933578
Limin Zhang, Jianling Yang, Haiming Wang, Xiangdong Peng, Dapeng Qu, Suying Jiao, Ruimin Bai, Qili Xin
AbstractObjective. To analyze the causes of unplanned resurgery, and provide an objective basis for the quality evaluation and improvement of the hospital's medical treatment services. Method. A retrospective analysis of 40 cases of unplanned resurgery in a hospital in 2012 was carried out. Result. The rate of occurrence of unplanned resurgery was 0.55% in the hospital in 2012; the main causes included postoperative bleeding, inconsistency between the results of the intraoperative frozen section examination and the pathological examination, which needed further consultation, and incision dehiscence. The proportions of these were 55%, 13% and 10%, respectively. Conclusion. Our department should strengthen perioperative management; the hospital should consider unplanned resurgery as the focus of medical quality management and strictly implement operation grading management and reauthorization systems to decrease the incidence of unplanned resurgery.
AbstractObjective。分析计划外手术发生的原因,为医院医疗服务质量评价和改进提供客观依据。方法。对2012年某医院40例计划外手术进行回顾性分析。结果。2012年全院计划外手术发生率为0.55%;主要原因为术后出血、术中冰冻切片检查结果与病理检查不一致,需进一步会诊、切口开裂。这些比例分别为55%、13%和10%。结论。加强围手术期管理;医院应将非计划性手术作为医疗质量管理的重点,严格实施手术分级管理和再授权制度,降低非计划性手术的发生率。
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引用次数: 0
Probe of the New Pattern of Mutual Evaluation of Medical Records Among Hospitals 医院病案互评新模式探讨
Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.935991
Ye Peng, Xugang Zhang, Wenxuan Zheng, Xiufang Yang, Na Xie, Yichao Han, Xiu-Li Zhang
AbstractThe quality of medical records is the focus of medical quality management. It is critical to improve the quality of medical records and strengthen the quality management of medical records. Since the system of mutual evaluation of medical records has been implemented, our hospital and other 3A hospitals within the province, have learned strengths from each other and overcome our weaknesses, taken effective quality control measures, and greatly improved the integrity of information in the first pages of medical records, the details of discharge records and discharge orders, copies of the course of diseases, the connotation of the ward rounds made by senior physicians, failure in modifying medical records, and so on. As a result, the quality of medical records has improved comprehensively. Meanwhile, mutual evaluation has improved the quality controllers’ working skills in the quality control of medical records and fully aroused the clinician's enthusiasm for the self-control of the quality of medic...
摘要病案质量是医疗质量管理的重点。提高病案质量,加强病案质量管理至关重要。病案互评制度实施以来,我院与省内三甲医院相互学习,取长补短,采取有效的质量控制措施,病案首页信息的完整性、出院病历明细、出院医嘱、病程复印件、资深医师查房内涵等方面都有了很大提高。修改病历失败,等等。病案质量得到全面提高。同时,相互评价提高了质控人员在病案质量控制中的工作水平,充分调动了临床医生对病案质量控制的积极性。
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引用次数: 0
Investigation of the Situations of Reviewing Application Materials of a Patient's Agent for Medical Record Copying 病案复制患者代理人申请材料审核情况调查
Pub Date : 2014-06-09 DOI: 10.3109/23256176.2014.927180
Yuqi Liu, Xiaogang Hao, Hongli Wang, Y. Xi
AbstractObjective. To survey related situations of the application materials submitted by a patient's agent for medical record copying, to discuss policy formulation and methods to reduce work pressure on the copying staff in the hospital. Method. Investigating related situations of the review of application materials of a patient's agent for medical record copying at twenty-eight 3A hospitals in Beijing. Result. Hospitals differ in the contents of application materials required to be submitted, the retention of such materials and the methods of disposal of special situations. In the past five years, a total of three complaints have been caused due to lax reviewing. Conclusions. The hospital should adopt feasible ways to inform patients or their agents of necessary materials for copying medical records in advance, so as to ensure that the authorization of a patient meets the requirements. Meanwhile, the system should also be applicable and specific, so that most people can grasp it.
AbstractObjective。调查患者代理人提交病历复印申请材料的相关情况,探讨制定政策和方法,减轻医院复印人员的工作压力。方法。调查北京市28家三甲医院病历复制患者代理人申请材料审核的相关情况。结果。各医院要求提交的申请材料的内容、材料的保留以及特殊情况的处理方法都有所不同。在过去五年中,由于审查不严而引起的投诉共有三起。结论。医院应采取可行的方式,提前告知患者或其代理人复制病历所需的材料,以确保患者的授权符合要求。同时,该制度还应具有适用性和针对性,使大多数人都能掌握。
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引用次数: 0
Influence of Clinical Pathway on Main Hospitalization Indexes of Chronic Obstructive Pulmonary Diseases 临床路径对慢性阻塞性肺疾病主要住院指标的影响
Pub Date : 2014-06-09 DOI: 10.3109/23256176.2014.925203
Q. Ye, Libo Zhang, Min He
AbstractObjective. To compare the changes in the main hospitalization indexes before and after the implementation of clinical pathway for chronic obstructive pulmonary diseases, during the recent six years. Method. Retrospective analysis of 1649 medical records fitting the clinical pathway of chronic obstructive pulmonary diseases between 2008 and 2013 is carried out, and the changes in the main hospitalization indexes are compared; the main hospitalization indexes include days of hospitalization, total hospitalization expense per person, nursing expense per person and so on; and the data are analyzed by using the SPSS17.0 software system. Result. Before and after the implementation of the clinical pathway, the average days of hospitalization, the total hospitalization expense per person, western medicine expense per person, nursing expense per person and bed expense per person for the patients with chronic obstructive pulmonary diseases are reduced to a certain degree (P < 0.05). Conclusion. The implemen...
AbstractObjective。比较近6年来实施慢性阻塞性肺疾病临床路径前后主要住院指标的变化。方法。回顾性分析2008 - 2013年符合慢性阻塞性肺疾病临床路径的1649份病历,比较主要住院指标的变化情况;主要住院指标包括住院天数、人均住院总费用、人均护理费用等;采用SPSS17.0软件系统对数据进行分析。结果。实施临床路径前后,慢性阻塞性肺疾病患者的平均住院天数、人均住院总费用、人均西药费用、人均护理费用、人均床位费均有一定程度的降低(P < 0.05)。结论。implemen……
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引用次数: 0
Problems in the Management of Electronic Medical Records at a Hospital and the Countermeasures 某医院电子病历管理中存在的问题及对策
Pub Date : 2014-06-09 DOI: 10.3109/23256176.2014.925201
Yunhong Wu, Z. Zeng, Wei-Tse Tang, Yi Wu, Donglin Li
AbstractThe management of Electronic Medical Records (EMRs) is an important part of hospital information construction. Its application improves the medical quality, the work efficiency, and the collection, analysis and reporting of medical information. Since the implementation of the EMR system in the hospital in 2011, there have been problems such as the non-standardization of outpatient information, defects in the flow setting, inconsistency between the contents of the paper-based medical records and the EMRs, failure to achieve the quality control requirement, management being out of place, information construction lacking accordance with the standards of the Ministry of Health, lack of training, and other issues. We should perfect the system flow setting, optimize the information integration, and strengthen the training, to promote the gradual development of EMRS and to make it better for clinical services.
摘要电子病案管理是医院信息化建设的重要组成部分。它的应用提高了医疗质量和工作效率,以及医疗信息的收集、分析和报告。该院自2011年实施电子病历系统以来,存在门诊信息不规范、流程设置存在缺陷、纸质病历内容与电子病历内容不一致、达不到质量控制要求、管理不到位、信息化建设不符合卫生部标准、缺乏培训等问题。完善系统流程设置,优化信息整合,加强培训,推动电子病历逐步发展,更好地为临床服务。
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引用次数: 0
期刊
Chinese Medical Record English Edition
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