基于三级公立医院绩效考核的病案首页缺陷分析

Analysis on the Defects in the Front Pages of Medical Records based on the Performance Appraisal of a Tertiary Public Hospital

目的分析基于三级公立医院绩效考核的某三甲医院病案首页数据质量缺陷,提出改进方案。方法抽取2019年1月1日-8月31日住院病案首页专项质控8670份,对缺陷利用SPSS17.0进行统计分析。结果4月份对临床医师和编码员加强培训后,5月至8月病案首页总体缺陷率持续下降,从25.41%下降至17%。缺陷构成主要为诊疗信息,占比45.16%,主要诊断选择及编码错误等;其次为住院过程信息,占比34.2%,如入院途径、离院方式填写错误;基本信息,占比15.76%,漏填新生儿体重等;费用信息占比4.9%,漏填住院总费用等。结论临床医师不重视和填写规则不熟悉、编码员编码水平不足、信息系统功能不完善是导致首页缺陷的主要原因。应对临床医师及编码员专项培训、质控及考核,完善首页数据质控软件功能,对持续提高病案首页数据质量、做好三级公立医院绩效考核工作具有重要意义。

Objectives To analyze the data quality defects in the front pages of medical records in a Three A and Tertiary Hospital based on the performance appraisal of a tertiary public hospital,and propose an improvement plan.Methods To summarize the defects of special quality control on the top page of medical records discharged from January to August of 2019,and the software of SPSS17.0 was used to perform the statistical analysis.Results After strengthening training for clinicians and coders in April,the overall defect rate of the top page of medical records continued to decrease from 25.41%to 17.00%from May to August.The main defects of the front pages of medical records were diagnosis and treatment information with the proportion of 45.16%,the main diagnosis selection and coding errors.The secondary important defects included the hospitalization process information(such as the incorrect way of admission and leaving hospital),the basic information(such as missing neonatal weight,etc.)and the cost information(such as missing the total hospital expenses,etc.).The corresponding composition ratios were 34.20%,15.76%,and 4.90%respectively for the three secondary important defects.Conclusions The main reasons for the front pages defects of medical records were that the clinicians did’t pay attention to it and were not familiar with the filling rules,the coding level of the coders was insufficient,and the function of the information system was imperfect.Therefore,strengthening the special training,quality control and assessment for clinicians and coders,and improving the function of quality control software for the data of the front pages were of great significance to continuously improve the data quality of the front pages of medical records and did a good job in the performance appraisal of tertiary public hospitals.