死因链填写质量缺陷分析与对策建议 -《中国卫生质量管理》

文章信息/Info

Keywords:: Cause Chain of Death; Cause of Death; Death Medical Records; Writing Quality

摘要:: 目的分析死因链填写质量缺陷原因，提出对策建议，提高死因链填写质量。方法采用回顾性分析法，对2017年7月-2018年12月的1 054份死亡证明书中死因链填写内容进行分析。结果在215例存在填写质量缺陷的死因链中，发现存在1项或多项填写内容质量缺陷的共计295频次。其中，疾病诊断填写不规范150频次，占50.85%；死亡原因填写内容不完整70频次，占23.73%；不符合格式填写要求16频次，占5.42%；与复核病案记录内容不一致 59频次，占20.00%。结论准确、完整的死因链可清晰展现患者的死亡原因，是死因统计最重要的信息依据。因此，医院应加强临床医师的基础知识培训，确保死因链填写的准确性，持续发挥质量监管作用等。

Abstract:: To analyze the causes of quality defects in death cause chain filling and take corresponding measures to improve the writing quality of the cause chain of death. MethodsThe retrospective analysis method was used to analyze the contents of the cause of death chain in the death certificate of 1,054 cases from July 2017 to December 2018.ResultsIn the 215 cases of cause of death with filling quality defects, one or more filling contents were found to have quality defects with a total of 295 times. Among them, the non-standard diagnosis was filled for 150 times, accounting for 50.85%. The cause of death was incomplete for 70 times, accounting for 23.73%. It didn't meet the format requirements for 16 times, accounting for 5.42%; and it was inconsistent with the contents of medical record review for 59 times, accounting for 20.00%.Conclusion Accurate and complete cause chain can clearly display the cause of death of patients with scientific and objective logic, which is the most important source of death report and death statistics for health departments at all levels. The hospital should strengthen the basic knowledge training of clinicians, strengthen the accuracy of the death chain filling, and continue to play the role of quality supervision,etc.