摘要
目的提高临床诊断(入院诊断与出院诊断)和影像诊断的符合率,减少漏诊、误诊的发生。方法对我院2009年3月-5月出院病案中随机抽取393份,进行回顾性研究分析。结果入院诊断与出院诊断符合率为96.69%;影像诊断与出院诊断符合率为97.71%;影像诊断之间不一致的占样本病案的3.56%;7例存在临床诊断及影像诊断的误诊、漏诊。结论临床诊断与影像诊断符合率的高低直接反映医院医疗质量管理水平和医疗技术水平。病案质控是提高病案质量的有效监督环节,可以发现各种缺陷,通过反馈形式,使医疗、医技及护理对存在的种种病案缺陷加以整改,从而促进临床诊断的进一步提高。
Objective to raise the coincidence rate of clinical diagnosis（the diagnosis admitted to hospital and hospitalization diagnosis） and image diagnosis for reducing missing diagnosis and misdiagnosis.Methods a retrospective research analysis on 393 medical records selected randomly from March to May in 2009 in our hospital.Results the coincidence rate of the diagnosis admitted to hospital and hospitalization diagnosis is 96.69%;the coincidence rate of image diagnosis and hospitalization diagnosis is 97.71%; image diagnosis are inconsistency taking up the 3.56% of sample medical records;seven of them exist missing diagnosis and misdiagnosis in clinical diagnosis and image diagnosis.Conclusions The high and low coincidence rate of clinical diagnosis and image diagnosis directly reflect hospital medical quality management level and medical technique level.Medical records quality control is an effective supervision segment of improving their quality,which can find out defects.Through feedback,it can rectify and improve medical records defeats in medical,medical technical and nursing,for promote further improvement of clinical diagnosis.
出处
《中国病案》
2011年第1期49-50,共2页
Chinese Medical Record
基金
山西省吕梁市科技攻关项目(2008rkx-02)
关键词
临床诊断
影像诊断
符合率
病案质控
clinical diagnosis
image diagnosis
coincidence rate
medical records quality control
