基于三级公立医院绩效考核的住院病案首页质控效果评价

Effect Evaluation of the Quality Control System of Medical Records Front Pages Based on Performance Assessment of Tertiary Public Hospital

目的通过住院病案首页质控提高住院病案首页质量,促进医院精细化管理,为三级公立医院绩效考核提供客观、准确、高质量数据。方法建立医院的住院病案首页质控体系,收集某院2018年7月1日至2019年6月30日所有出院病案共41237份,采用SAS9.4对比分析质控前后住院病案首页填写的错误率情况。结果建立住院病案首页质控体系后,住院病案首页的强制性、合理性、逻辑性三类错误率较质控前均有所下降,主要表现为:是否有出院31日内再住院计划的填写错误率较质控前下降了45.44%,差异有统计学意义(χ~2=8501.2744,P<0.0001),职业填写错误率较质控前下降了72.43%,差异有统计学意义(χ~2=22729.1288,P<0.0001);出生地址、工作单位地址、颅脑损伤患者入院前昏迷时间的填写错误率较质控前均有所下降,差异有统计学意义(P≤0.0001);三级医师签名的错误率较质控前均有所下降,差异有统计学意义(P<0.05)。住院病案首页质控前后半年,某院住院病案首页错误的病案占比总体呈明显下降趋势。结论建立住院病案首页质量控制体系有效提升了住院病案首页数据质量,还需紧扣住院病案首页质控评分环节,加大病案督查和培训力度,各部门共同协作,完善某院住院病案首页的质控系统。

Objective By controlling the quality of medical record home page,in order to improve the quality of the medical record and hospital’s delicacy management,to provide the objective and accurate data for the performance assessment of tertiary public hospital.Methods Established hospitalmedical record quality control system,and using SAS9.4 todo comparative analysis of 41237 medical records home page from July 1,2018 to June 30,2019 before and afterquality control about error rate.Results The rate of compulsory error and reasonable error and logic error all reduced after quality control:The error rate of readmission during 31 days after leaving hospital had reduced by 45.44%and difference was statistically significant(χ~2=8501.2744,P<.0001),while the error rate of profession had reduced by 72.43%and difference was statistically significant(χ~2=22729.1288,P<.0001),the birth address,working address,coma period before admission of craniocerebral injury patients,those error rates were lower than before and differences was statistically significant(P≤0.0001),the error rate of signatures about three levels doctors was lower than before and differences was statisticallysignificant(P<0.05).During the period of quality control,the medical records which home pages included error items was totally in apparent declining tendency.Conclusion The medical record quality control system can improve medical record completed rate and accuracy rate.On the other hand,it should be continue to improve supervision and training of medical records,while the process of medical records home page quality control score should be focused on,and a number of departments should work together toimprove the quality control system.