日照市中医医院

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1、日照市中医医院病历终末质控简报质控科2015年03月内部资料请勿外传17一、2015年3月份病历审阅病历汇总内科系列病历汇总科室名称平均分格式质控问题病历数病历总数格式质控问题率24小时上交率内涵质控合格病历数内涵质控问题病历数内涵质控病历总数内涵质控合格率名次急诊科100080.00%100%606100.00%1小儿二科982516315.34%100%39039100.00%1血液科97.585115.69%100%23023100.00%1针灸科(一组)97.941614411.11%100%9619798.97%2内分泌科97.651710116.83%10

2、0%6626897.06%3肿瘤科97.472813720.44%100%6526797.01%4脑病一科97.874313831.16%100%6326596.92%5脑病二科一病区97.253513226.52%100%7327597.33%6二病区97.25239923.23%100%5235594.55%平均97.255823124.88%100%125513096.15%感染/肝病科肝病一科97104621.74%100%3813997.44%7肝病二科97.53210929.36%100%4434793.62%平均97.254215527.09%100%8

3、248695.35%小儿一科96.983523814.71%100%6947394.52%8心血管病一科97.223313823.91%100%8158694.19%9风湿肾病科97.142211219.64%100%6146593.85%10呼吸科呼吸病房97.453816223.46%100%105410996.33%11加护病房97.334613733.58%95.20%8779492.55%一体化病房96.79329434.04%94.80%6787589.33%平均97.1911639330.36%97%2591927893.17%保健病房96.973072

4、41.67%100%3533892.11%12心血管病二科96.834112832.03%100%4144591.11%13重症医学科96.9102638.46%100%63966.67%14总数97.51524223523.44%99%111758117595.06%外科系列病历汇总科室名称平均分格式质控问题病历数病历总数格式质控问题率24小时上交率内涵质控合格病历数内涵质控问题病历数内涵质控病历总数内涵质控合格率名次肛肠科97.9198125.93%100%65065100.00%1骨伤五科97.88169417.02%100%59059100.00%1骨伤一科9

5、7.81219320.43%100%52052100.00%1颈肩腰腿痛一体化骨伤三科97.84121786.74%100%9419598.95%2针灸(二组)97.781813213.64%100%79079100.00%平均97.813031010.19%100%173117499.48%妇产科(产科组)97.754031512.70%100%123212598.40%3脑病三科97.361411112.61%100%5715898.28%4眼科97.48219422.34%100%3613797.30%5骨伤二科97.42319632.29%100%361379

6、7.30%5外三科97.432811524.35%100%5826096.67%6外一科97.534213630.88%100%5535894.83%7妇产科(妇科组)97.675722525.33%98.50%7157693.42%8耳鼻喉科97.38166524.62%100%4034393.02%9骨伤四科97.21349535.79%100%4144591.11%10胃肠病科胃肠病科(一组)97.573212725.20%100%3513697.22%11胃肠病科(二组)97.694113530.37%100%3263884.21%平均97.637326227

7、.79%100%6777490.72%外四科96.874313432.09%100%5566190.16%12口腔科95.52728.57%100%41580.00%13总数97.41487223321.80%99.92%99237102996.40%17四、2015年3月份医疗文书存在的问题（非手术科室）风湿肾病科：311387蔡明英刘宗涛3入院证空项.中药医嘱时间与病程不符。312746郭长林刘宗涛3返修住院证空项.输液粘贴单姓名错。313889申延常刘宗涛4返修首页主任.副主任.主治.住院医师.质控医师未签字。312130郑世悦孟令芳5返修入院