基于绩效考核为导向的住院病案首页书写培训效果评价

Effect Evaluation on the Training of Front Pages of Medical Records Based on Performance Appraisal

目的结合绩效考核进行病案首页培训,促进医院住院病案首页质量。方法抽取2018年1月1日-2018年11月30日2970份住院病案首页及2019年1月1日-2019年11月30日2970份培训前后的27个住院科室的5940例住院病案。对入院病情、临床路径、离院方式、出院31天内再住院计划、主要诊断、主要手术及操作、其他诊断填写完整、现住址、疾病分型等9项指标进行数据统计。结果住院病案首页错误总频次由培训前的1895次下降到培训后的739次,χ^2=533.633,P<0.001,差异有统计学意义。培训后9项指标分项错误频次均低于培训前,经卡方检验,P<0.001,差异有统计学意义。高优指标及低优指标培训后均有所上升。结论以绩效考核为导向进行住院病案首页培训,重视并规范病案首页填写,可为多维度评价医院管理助力。

Objective To conduct training of front pages of medical records combine with the performance appraisal,thus to promote the quality of front pages of medical records effectively.Methods Each month with departments as the unit,27 inpatient departments pressed the hospital number from small to large spot check the first 10 hospital numbers,a total of 2970 medical records per year in January to November.The data quality control and arrangement of 9 indexes before and after training were carried out on admission condition,clinical path,way of leaving hospital,re-hospitalization plan within 31 days of discharge,main diagnosis,main operation and operation,complete other diagnosis,current address and disease classification.Results Before and after the training,the χ^2 value of the total data before and after the training was 533.633,the P value<0.001,the difference was statistically significant;Before and after the training,the P value of the chi-square test of 9 indexes was<0.001,the difference was statistically significant.Nine indicators selected the proportion of performance-oriented data before and after the training comparative analysis,high-quality indicators and low-level indicators have increased after the specification.Conclusion Taking the performance appraisal as the guidance,pays attention to and standardizes the filling,for the multi-dimensional evaluation hospital management help.