某三甲医院病案首页数据质量分析

Data Quality Analysis of the First Page of Medical Records in a Three Grade Hospital

目的通过抽查病案首页,了解病案首页数据质量情况,为即将开展的DRGs工作打好基础。方法抽查2016年9月-2017年2月88个亚专科共3130份病案首页,对病案首页的基本信息、医疗信息、附页信息填写质量情况逐项检查并归类分析。结果 3130份病案首页填报完整率为5.39%,项目填报完整率为94.78%,基本信息填报完整率为8.08%,医疗信息填报完整率为96.03%,湖南省附页信息填报完整率为95.5%。结论病案首页数据填报完整率较低的原因主要有书写者涉及人员多且责任心不强,对知识的掌握不准确等,医院通过利用计算机系统自动检测,开展病案首页质量管理培训,加强质控人员与临床医师面对面沟通交流及制定检查评分标准等措施,提高病案首页数据质量。

Objective Tolay a good foundation for the upcoming DRGs by examining medical record front page,knowing the data quality of the medical record front page.Methods 3130 medical record were selected from 88 subspecialities from September 2016 to February 2017 and were checked for front pages. Basic information, treatment information, and attachment information were checked item by item and analyzed by classification.Results Among the 3130 medical records, complete rate of front page filling was 5.39%, complete rate of item filling was 94.78%,complete rate of basic information filling was 8.08%, complete rate of treatment information filling was 96.03%,complete rate of attachment filling was 95.5%.Conclusion The mainly reasonsof low complete rateof the medical record front page aremany writers involved and their sense of responsibility are not strong, the knowledge is not accurate,etc..Through the use of computer systems automatically detect, carrying out medical records frontpage quality management training, strengthen face-to-face communication between quality control person and clinicians, and setting up the measures for checking and grading,the hospital could improve the medical recordfront page data quality.