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目的了解病案首页血液检查HbsAg、HCV-Ab、HIV-Ab及血型的填写质量,有针对性的制定解决对策。方法运用PowerBuilder程序,提取某院2012年9-11月3106份出院病人病案首页及检查结果中,HbsAg、HCV-Ab、HIV-Ab及血型各项数据并查找缺陷,分析缺陷原因,制定干预措施。结果 3106份病案首页中142份存在缺陷,缺陷率4.57%,有90.14%的问题为检验结果为“阴性”或“阳性”而病案首页却填写“未查”。干预后再提取某院2013年1-3月2435出院病人病案首页及检查结果,其中28份存在缺陷,缺陷率降低为1.15%。结论加强各级质控,强化医生责任意识、法律意识,研发相关软件,是降低病案首页HbsAg、HCV-Ab、HIV-Ab及血型填写缺陷的有效方法。
Objective To understand the quality of the first blood test HbsAg, HCV-Ab, HIV-Ab and blood type, and to formulate solutions to the problem. Methods The data of HbsAg, HCV-Ab, HIV-Ab and blood type in 3106 cases of discharged patients from September to November in 2012 were searched by using PowerBuilder program to find the defects, analyze the causes of the defects and make interventions . Results There were 142 defects in the first page of 3106 cases, with a defect rate of 4.57%. There were 90.14% of the questions as “negative” or “positive” while the first page of the medical record was filled in “not checked”. After the intervention, the first page and the examination results of discharged patients in January-March 2013 were collected from a hospital. Among them, 28 were defective and the defect rate was reduced to 1.15%. Conclusion Enhancing quality control at all levels, strengthening doctor’s sense of responsibility, legal awareness and developing related software are effective methods to reduce HbsAg, HCV-Ab, HIV-Ab and blood type defects in the first page of medical records.