摘要
目的分析探讨住院病案首页填写存在的缺陷问题,进一步提高病案首页书写质量。方法计算机检索万方、维普、中国知网数据库,收集2000年1月-2016年3月相关病案首页文献,绘制森林图,由异质性检验结果选择随机效应模型进行数据合并,对病案首页组成项目进行分组分析,进行敏感性和发表偏倚分析。结果此次Meta分析共纳入12篇文献,病案首页合并缺陷率为6.6%（95%CI：5.3%～7.9%）,基本信息缺陷24%,诊断信息缺陷18.9%,手术信息缺陷9.4%。结论病案首页缺陷率较高,各项目填写缺陷问题不容忽视,首页缺陷内容中缺陷率较高表现为基本信息情况（姓名、地址、身份证号码、联系人错误）、诊断信息（诊断名称、主次顺序颠倒问题）以及手术信息（手术切口问题）的填写。病案管理专职人员和临床医师需进一步提高书写质量意识,确保病案首页的准确性和真实性,促进病案质量管理工作的完善。
Objective To analyze the filling defects existing in the front sheet of medical records, and improve the writing quality. Methods To collect related articles on front sheet of medical records by searching Wanfang Data,VIP and CNKI database. Drawing forest plot and random effect model was selected to merge data according to the results of heterogeneity test. Subgroup analysis, sensitivity and publication bias were also done for the front sheet of medical records. Results Twelve articles were eligible. The combined defect rate was 6.6%（95%CI：5.3%～7.9%）,and all the defect rate were 24%,18.9%,9.4% respectively for the basic,diagnostic and operation information. Conclusions The defects rate of front sheet writing was high and problems of filling should not be neglected. Defect rate of basic（defects of name, address and contact）, diagnostic（defects of diagnosis, primacy sequence reversal） and operation（defects of surgical incision） information were higher. The medical records management professional staff and clinical doctors should improve the consciousness of the writing quality of medical records to ensure the veracity and authenticity, so as to promote the quality management of medical records.
出处
《中国病案》
2016年第7期63-65,共3页
Chinese Medical Record
关键词
病案首页
缺陷
META分析
Front sheet of medical records
Defects
Meta analysis
