门诊医生工作站主要诊断填写中的问题及措施

摘要

目的：规范门诊医生工作站主要诊断的填写。方法回顾性调查我院2015年1月~12月门诊信息主要诊断填写情况。结果67849条门诊信息中主要诊断填写缺陷率37.20%，其中主要诊断资料不全占15.96%，比例最大。结论提高医务人员的认识，加强培训，优化系统功能，严把主要诊断录入关是提高主要诊断正确率的有效办法。%Objective To standardize the main diagnosis of outpatient doctor workstation. Methods A retrospective survey was conducted in December ~2015, January 2015 in our hospital, the main diagnostic information was completed. Results The main diagnostic rate of 67849 out of 15.96%outpatients was 37.20%, among which the main diagnostic data was not total, and the proportion was the largest. Conclusion To improve the understanding of medical staff, strengthening training, optimize the function of the system, strictly control the main diagnosis book entry is a effective way to improve the correct rate of diagnosis is mainly.