住院病案首页录入方法的优化

The Type-in Methods Optimization of Front Pages of Hospitalized Medical Records

目的探索病案首页录入的优化方案,减轻病案首页填写工作量、缩短录入时间、提高录入速度、提升首页数据质量,为统计分析奠定坚实的基础。方法利用Delphi XE开发语言、Oracle数据库,优化数据表和录入方法。选取2015年出院病案信息中有手术操作并且出院诊断数多于4个的病案,再从中先后两次随机抽取2536份、1215份病案,并分别用优化前、后的病案软件录入审核。数据库后台自动记录下每份病案的录入时间,采用SPSS 22.0对优化前后的数据进行t检验。结果通过优化软件,录入病案首页时间明显减少,单份病案录入总用时,改进前需要1166.60?207.91秒,改进后需要302.71?32.36秒,经t检验,改进前、后的录入时间差别具有统计学意义(t=143.99,P=0.000)。采用该软件生成的四川省病案首页(卫统4表)上报数据,从完整性、规范性、逻辑性三方面评分结果,由原来的90?1.2分,提升到98?1.8分。结论探索病案首页录入优化既保证了病案首页信息来源统一、录入简捷高效,缩短了病案首页录入时间,提高了病案首页录入速度,减轻了操作员工作量,又实现了数据客观准确,提升了信息质量及使用价值。

Objectives To explore the optimization program of the front pages of medical records,shorten the time of entry of the front pages of medical record,improve entry speed,reduce the workload of the front pages of medical record,improve the quality of the homepage data,to lay a solid foundation for statistical analysis. Methods The development language of Delphi XE and Oracle database were adopted to optimize the data table and type-in methods. The medical records who had operations as well as contained more than 4 discharged diagnosis in 2015 were selected,then made selection of 2536 cases and 1215 cases of medical records from them randomly,and then made type-in check with the medical records software before and after the optimization respectively. The database could record the type-in time of each medical record automatically in the backstage,and SPSS software was applied to conduct T test on the data before and after the optimization. Results The input time was decreased obviously by the optimization of software. The total time of average medical records input process had decreased from 1166.60±207.91 seconds to 302.71±32.36 seconds after the optimization. The difference of input time had statistical difference before and after the optimization by t test （t =143.99,P =0.000）. The report data of front pages of medical records in Sichuan province formed by this software was increased from 90±1.2 points to 98±1.8 points from the three aspects of integrity,normalization and logicality. Conclusions The exploration of the type-in optimization of front pages of the medical records could ensure the unify source of the information,the input process was simple and effective,the input time was shortened,the input speed was improved,the workload of the operator was reduced,and the information quality and the use value were improved.