12367份病历首页HQMS网络直报的质量分析

The Quality Analysis of HQMS Network Report of 12367 Front Sheet of Medical Record

目的规范病案首页填写,提高HQMS网络直报信息质量。方法依据国际疾病分类第十版(ICD-10)的疾病主要诊断填写要求及选择原则。按照《广西病历书写规范》标准进行首页质量分析,根据HQMS的上报病案首页数据的要求。本文分析了目前信息网络直报病案首页填写的质量。结果 12367份病案中,有缺陷的病案首页累计2819例,占22.80%。缺陷包括基本情况16.99%、出院诊断填写20.01%、手术、操作填写21.67%、疾病和手术操作分类8.90%、三级医师签名不及时28.80%、其他错误3.62%。结论采取对临床医生、病案编码人员等相关人员进行规范化岗位培训、建立院科两级病案首页质量监控体系、增设病案质量控制岗位等措施,可以提高病历首页质量。

Objective To standard the filled out of the front sheet of medical record, improve the quality of Hospital quality monitoring system （HQMS） network report. Methods Analyzing the quality of the front sheet of medical record according to main diagnosis fill in request and selection principle of ICD-10 and Guangxi medical record writing standards by Hospital quality monitoring system network report. Results A total of 2,819 cases have defects, accounting for 22.80%. The defecting types were as follows： basic information（ 16.99% ）, discharge diagnosis （20.01%）, surgery and operation （21.67%）, the classification of diseases and surgery and operation （8.90%）, and not timely signature（28.80%）, other errors（3.62% ）. Conclusion We should settle the standardization on-the-job training for clinicians and coders. Furthermore, two levels of monitoring system for hospital-to-clinical department was urgent to build, and more posts should be added for medical record quality control.