四川省卫生统计直报系统病案首页数据质量分析

Analysis on medical record first page data quality from Sichuan health statistics reporting system

[目的]对四川省卫生统计直报系统病案首页的质量进行分析,探讨控制病案首页质量的方法。[方法]随机抽取中医病案首页20,000份,西医病案首页19,964份,对病案首页的各个项目进行分类统计。[结果]病案首页漏填率高,中医病案首页最高缺项率为88.82%,错填率高,不足一周岁的儿童年龄、新生儿出生体重、新生儿入院体重填"0"情况严重。[结论]四川省各级医院住院病案首页报送质量不太理想,应统一住院病案首页版本,统一住院病案首页信息标准,完善全省病案首页管理系统以提高病案首页的质量。

Objective Analysis on medical record first page data quality from Sichuan health statistics reporting system, to explore the method to control the quality of medical record first page.Methods randomly selected traditional Chinese medical record first page 20,000 and western medicine medical record 19,964, classified statistics the medical record of each project.Results Missing filing on medical record first page was high. The highest missing items rate of Chinese medical record was 88.82%, wrong fill rate was high too. It was serious that filled ＂0＂ for less than one year old child＇s age, birth weight, neonatal admission weight.Conclusions It needs to unify hospitalization medical record first page versions, and hospital medical record first page information standards, improve the provincial medical record first page management system the quality.