医疗保险审核中病案书写常见问题分析
Common problems in writing of medical records found at medical insurance verification
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摘要: 本文对医保中心审核的242份我院出院病案中常见问题进行分析,其中入院记录书写存在的问题为1.2%,出院诊断为2.8%,病程记录及手术记录不够详细为7.4%,医嘱、辅助检查与结帐清单不吻合为13%,针对此类问题提出防范对策。Abstract: Analyzed in this paper are the common problems found in 242 medical records when they were verified by the Medical Insurance Center of our hospital.Problems found in admission records,diagnosis at discharge,disease course and operation records,as well as doctor’s advice,accessory examination and settling account accounted for 1.2%,2.8%,7.4%,and 13%,respectively.Certain countermeasures were proposed for such problems.
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