住院病案首页主要诊断及主要手术填写的质量改进

Quality Improvement of Main Diagnosis and Main Operation Filling in the Front Page of Inpatient Medical Records

目的通过分析住院病案首页主要诊断和主要手术的填写缺陷,探讨质量改进措施,提高病案首页质量。方法以国家住院病案首页填写相关规定为依据制定医院质控考核标准,对2019年2月1日-2020年1月31日共59 516份住院病案的主要诊断和主要手术进行终末质量检查,比较分析2019年2月1日-2019年7月31日质控前与2019年8月1日-2020年1月31日质控后的各项指标。结果主要诊断与手术在质控前填写缺陷率分别为8.95%与3.70%,质控后填写缺陷率分别为2.44%与1.10%,P均小于0.05,质控前后差异具有统计学意义。结论经过质量改进后,建立了较为完善的专项质控体系,病案首页主要诊断、手术填写缺陷率明显下降,数据质量得到持续改进,为即将实施的DRGs付费打下坚实基础。

Objectives By analyzing the defects of the main diagnosis and operation filling in the front page of the inpatient medical records,this paper discusses the quality improvement measures to improve the quality of the front page of the medical record.Methods Based on the relevant regulations of filling in the front page of the national inpatient medical records,the hospital quality control assessment standards were formulated.The final quality inspection was carried out for 59 516 inpatient medical records from February 1 st,2019 to January 31 st,2020.The indicators before quality control(February 1 st,2019 to July 31 st,2019) and after quality control(August 1 st 2019 to January 31 st,2020) were compared and analyzed.Results The defect rate of main diagnosis and operation was 0.94% and 1.2% respectively in the early stage of quality control,and 0.38% and 0.56%respectively in the late stage of quality control,P value was less than 0.05,the difference was statistically significant.Conclusions After quality improvement,a relatively perfect special quality control system had been established.The main diagnosis and operation defect rate of the front page of the medical record had decreased significantly,and the data quality had been continuously improved,laying a solid foundation for the DRGs payment to be implemented in the hospital.