摘要
目的 分析住院病案首页填写缺陷的相关文献,为以提高住院病案首页书写质量提供参考。方法 以关键字“住院病案首页”和“缺陷”为检索词,系统检索2015年1月1日-2020年6月30日中国知网数据库(CNKI)、万方、维普数据库住院病案首页缺陷的相关文献,绘制森林图,当研究间存在异质性时选择随机效应模型,并进行敏感性和发表偏倚分析。结果 共纳入18篇文献,总样本量为294480例。Meta分析显示,住院病案首页缺陷的效应值为7.45%(95%CI:6.03%~9.19%),其缺陷主要表现为:基本信息缺陷占17.87%,如身份证号码、姓名、地址填写错误;手术信息缺陷占8.51%,如手术名称和操作、输血信息填写错误;诊断信息缺陷占7.86%,如诊断的顺序或名称填写不规范。剔除质量较低的文献,住院病案首页的总缺陷率为7.052%,敏感性较低;Begg检验Z<1.96,P>0.05,存在发表偏倚的可能性较小。结论 住院病案首页总体缺陷率较高,填写者主观重视程度和专项技能不足是造成填写缺陷的主要原因。应通过信息化手段、病案书写培训等方法提高病案管理专职人员和临床医师病案书写质量,重点改进基本信息、手术信息和诊断信息的填写缺陷问题。
Objectives To provide reference for improving the writing quality of the front page of inpatient medical records,this paper analyzed the related literatures about the filling defects of the front page of inpatient medical records in recent 5 years.Methods Keywords "front page of inpatient medical records" and "defect" were used as search terms.CNKI,Wanfang and VIP databases were systematically searched to collect literatures related to front page defect of inpatient medical records from January 1 st,2015 to June 30 th,2020.Forest maps were drawn and random effect models were selected when heterogeneity existed between studies.Sensitivity and publication bias were analyzed.Results A total of 18 literatures were included,with a total sample size of 294480 cases.The effect value of defects in the front page of inpatient medical records was 7.45%(95%CI:6.03%-9.19%),and the main defects were as follows:defects in basic information accounted for 17.87%,such as filling errors in ID number,name and address.Defects of surgical information accounted for 8.51%,such as errors in surgical name and operation and blood transfusion information.And diagnostic information defects accounted for 7.86%,such as the order or name of diagnosis was not standardized.Excluding literatures of low quality,the total defect rate of the front page of inpatient medical records was 7.052%,showing low sensitivity.Begg test Z0.05,the possibility of publication bias was small.Conclusions The overall defect rate of the front page of inpatient medical records was high.The main reasons for filling in defects were the subjective attention of the fillers and the lack of special skills.The quality of medical record writing should be improved by means of informatization and training of medical record writing,and the defects of filling in basic information,operation information and diagnosis information should be improved.
作者
黄芳
宋巨忞
魏薇
Huang Fang;Song Jumin;Wei Wei(The First Affiliated Hospital of Anhui Medical University,Hefei 230022,Anhui Province,China;不详)
出处
《中国病案》
2022年第3期17-19,共3页
Chinese Medical Record
基金
安徽省教学研究项目(2018jyxm0717)。
关键词
住院病案首页
缺陷
META分析
Front page of in-patient medical records
Defects
Countermeasures
Meta-analysis
