Analysis of problems on the homepage of inpatient medical records in the department of bone and soft tissue oncology
10.3969/j.issn.1671-332X.2024.03.011
- VernacularTitle:骨与软组织肿瘤科住院病案首页问题分析
- Author:
Lina GAO
1
;
Hongtao WANG
;
Chang LU
Author Information
1. 天津医科大学肿瘤医院//国家恶性肿瘤临床医学研究中心//天津市恶性肿瘤临床医学研究中心//天津市肿瘤防治重点实验室 天津 300060
- Keywords:
Bone and soft tissue tumors;
Homepage of inpatient medical records;
Problems;
Defects;
Countermeasures
- From:
Modern Hospital
2024;24(3):367-370
- CountryChina
- Language:Chinese
-
Abstract:
Objective The purpose of this article is to analyze the problem with the first page of inpatient medical re-cords in the Department of Bone and Soft Tissue Oncology of a certain hospital,in order to provide guidance for improving the quality of the first page of inpatient medical records.Methods A retrospective analysis was conducted on 2 979 inpatient medi-cal records from the Department of Bone and Soft Tissue Oncology of a certain hospital from April 1,2022 to August 31,2023.Excel was used to statistically analyze and record the occurrence of problems on the first submission of inpatient medical records.Results A total of 1 258 inpatient medical records had issues with the first submission of 2 979 inpatient medical records,with an incidence rate of 42.23％.A total of 2 149 defects were found on the homepage of 1 258 problematic medical records,among which 28.71％,22.57％,16.66％,13.49％,and 10.89％were other diagnostic errors,main diagnostic errors,pathological diagnostic errors,other surgical or operational errors,and main surgical or operational errors,respectively.Conclusion There are many pre quality inspection issues on the first page of inpatient medical records in the Department of Bone and Soft Tissue On-cology of a certain hospital,which should be taken seriously.The incidence rate can be reduced by strengthening training for clin-ical physicians,providing targeted guidance for coding personnel on filling out problems on the first page,improving pre submis-sion logic quality control in the Information Department,and strengthening performance evaluation.
