住院病案首页质量控制与改进措施探讨

Discussion on quality control and improvement measures of inpatient medical record

目的探讨住院病案首页质量控制与改进措施。方法选取某院2017年1月—6月出院的1 030份参与全省DRGs绩效评价的24个重点手术已编目病案,依据2016年国家卫计委发布的住院病案首页控制标准,指定资深编码员进行病案首页同步质量控制。及时采取针对性整改措施,保证病案首页的准确上传。同时,采用描述性方法,将缺陷记录在科室设计的质控表单内,月末用于统计及分析住院病案首页填报存在的缺陷,质控结果以月报的形式向全院进行公示。结果 1 030份出院病案首页填报有缺陷的共287份;主要缺陷有主要诊断及主要手术操作选择错误、不规范诊断、其他诊断及其他手术操作漏写漏编、病理编码错误、入院病情错误,共计318例次。结论住院病案首页质量尚有待提高。规范临床医师病案首页规范填写、加强编码员的培训与学习、增强首页编码质控力量、畅通临床与病案的沟通交流,是首页数据完整准确上传的有力保障,为DRGs的应用与推广保驾护航。

Objective To control the quality of the first page of inpatient medical records and to analyze the causes of the defects,and to take measures to improve the quality of the first page.Methods From 2017 Janurary to June months of 1 030 to participate in the province＇s DRGs performance evaluation of the 24 key operation cataloged according to medical records,medical records control standard of the National Guard Planning Commission released 2016,senior member of the medical record specifies the encoding quality control synchronization.Take corrective actions in time to ensure the accurate upload of the front page of medical records. At the same time,the descriptive method is adopted to record the defects in the quality control form designed by the Department,and the end of the month is used to analyze the defects existing in the front page of the inpatient medical record,and the quality control results are publicized to the whole hospital in the form of a monthly report.Results 1 030 copies of medical records to fill discharge defective and a total of 287;there are major shortcomings and main operation diagnosis operation selection errors,diagnosis,diagnosis and other other surgical operation,pathology haplography leakage error,error encoding admission condition is not standardized,a total of 318 cases.Conclusion The quality of home page of inpatient medical records needs to be improved. Specification for medical record in standard form,strengthen the clinician encoding member of the training and learning,enhance the clinical and medical record quality control encoding strength,smooth communication,is a strong guarantee to complete and accurate data of the first page upload,DRGs application and promotion of escort.