信息化建设对病案首页数据质量的影响

Influence of Informatization Construction to the Data Quality in Front Sheet of Medical Records

目的通过对病案首页填写质量分析,针对存在的缺陷,加强信息化建设不断提高病案首页信息质量。方法利用医院信息平台系统,采集某院2015年第一季度和第三季度的病案首页信息共50 371份,根据原卫生部2012年版住院病案首页质量填写要求,对病案首页质量进行评价分析。结果病案首页信息缺陷内容主要有患者基本信息不完善、出院诊断填写错误、临床路径误填漏填、疾病和手术操作编码不准确、血型误填、诊断符合情况错漏填等六项,通过加强信息化建设使病案首页信息填写缺陷率由第一季度的46.47%下降为第三季度的14.57%。结论强化病案首页的信息化建设,降低缺陷率,提高病案首页信息质量和有效利用。

Objectives Through conducting analysis and evaluation on the filling quality of front sheet of medical records, to strengthen informatization construction and improve the information quality of front sheet of medical records continuously aimed at the defects existing. Methods 50371 cases of information in front sheet of medical records from the first quarter to the third quarter in 2015 were collected from a hospital with the application of hospital information l^lafform system. To conduct evaluation analysis on the quality of front sheet according to the 2012 version filling rules of hospitalized medical records front sheet announced by the ministry of health. Results The mainly defects content of medical records front sheet included six items such as imperfect essential information of patients, error filling of discharged diagnosis, lack of clinical pathways, inaccurate diseases and operation coding, error fining of blood type and lack of diagnosis accordance situation. The filling defect rate of medical records front sheet had decreased from 46. 47% in the first quarter to 14. 57% in the third quarter through strengthening the informatization construction. Conclusions To strengthen the informatization construction of medical records front sheet could decrease defect rate, improve the information quality of front sheet and promote the effective application of information.