单项目质控在住院病案首页质量控制中的作用探讨

Discussion the Function of Single-item Quality Control in the Quality Control of Thehomepage of Inpatientmedical Records

目的通过分析单项目质控住院病案首页前后的结果,探究提高住院病案首页填写质量的有效途径。方法选取对病案首页离院方式进行单项目质控前的2019年1~3月28119份某三甲医院出院患者的病案数据作为对照组;单项目质控后的2020年1~3月的24297份出院患者病案数据作为观察组。以《住院病案首页数据质量管理与控制指标(2016版)》《住院病案首页数据填写质量规范(暂行)》《住院病案首页数据质量评分标准》三个文件作为质控标准依据,利用SPSS 20.0统计软件对两组终末病案首页离院方式填写缺陷率进行对比分析。结果观察组住院病案首页离院方式填写缺陷率0.32%,显著低于对照组的5.68%(P<0.05)。观察组在住院病案首页离院方式中医嘱离院的填写缺陷率0.05%,显著低于对照组的4.67%(P<0.05)。观察组住院病案首页离院方式代码、拟接收医疗机构名称错填率为0.29%,显著低于对照组的4.68%(P<0.05)。结论实施单项目质控住院病案首页可显著降低终末住院病案首页的填写缺陷率,提高了住院病案的整体质量。

Objective To explore the role of single item quality control on the first page of inpatient medical records in improving the filling quality of the first page of inpatient medical records.Methods The 28119 medical record data of discharged patients in a Three A and Tertiary Hospital from January to March 2019 before using the single-item quality control method on the homepage of inpatient medical records were chosen as the control group;the medical records data of24,297 discharged patients from January to March 2020 after using the single-item quality control method on the homepage of inpatient medical records were chosen as the observation group.Quality control standards were based on three documents,“Quality Standards for Inpatient Medical Record Homepage Data Filling(Interim)”,“Inpatient Medical Record Homepage Data Quality Management and Control Index(2016 Edition)”and“Inpatient Medical Record Homepage Data Quality Scoring Standard”.The SPSS 20.0 statistical software was used to compare the filling defect rate of the discharged hospital method on the front page of the final medical records of the two groups.Results The defect rate of leaving hospital on the first page of inpatient medical records in the observation group was 0.32%,which was significantly lower than 5.68%in the control group(P<0.05).In the observation group,the filling defect rate of leaving hospital according to the TCM order on the first page of inpatient medical records was 0.05%,which was significantly lower than 4.67%in the control group(P<0.05).In the observation group,the error rate of leaving mode code on the first page of inpatient medical records and the name of medical institution to be received was 0.29%,which was significantly lower than 4.68%in the control group(P<0.05).Conclusion The filling defect rate of the homepage of finalinpatient medical records could be significantly reduced and the overall quality of inpatient medical records could be improved with the method of single-item quality control on the homepage of inpatient medical records.