住院病案首页数据质量缺陷分析及对策

Quality Defect Analysis and Countermeasures of the Front Sheet of Medical Records

目的通过对某三级综合医院病案首页的填写情况进行检查,分析和探讨住院病案首页数据质量的影响因素及其对策,提高病案首页信息质量。方法依据国家卫计委《住院病案首页数据填写质量规范(暂行)》,对2016年4月(对照组)和2016年8月(观察组)全部出院患者病案首页信息质量进行对比研究。结果观察组病案首页项目填写缺陷率、疾病诊断名称缺陷率、主要诊断选择缺陷率、疾病编码选择缺陷率、手术及操作编码缺陷率均明显低于对照组,差异具有显著性意义(P<0.005)。结论通过建立医院疾病诊断库以及手术操作库、改进病案首页管理流程、加强临床医师培训、增强医院信息化支持等措施的实施,有助于病案首页数据质量的提升。

Objectives Through the examination of the front sheet of medical records in a provincial public hospital,the influencing factors and countermeasures of the front sheet of medical records were analyzed and discussed, and the information quality of the front sheet of medical records was improved. Methods According to the National Health Commission ＂hospital medical records home data to fill in quality standards（temporary）＂, A comparative study was conducted on the information quality of the front sheet of medical records in April, 2016（control group） and August 2016（observation group）. Results The defect rate of the basic information items, the defect rate of disease diagnosis,the defect rate of the main diagnosis selection, the defect rate of disease coding, and the defect rate operation coding of the observation group are significantly lower than those of the control group,the differences are significant（P0.05）.Conclusions Through the establishment of hospital diagnosis and surgical operation library, improve the management process of the front sheet of medical records, strengthen the training of physicians, enhance information support and other measures, the quality of the front sheet of medical records will be improved. 1