病案首页对统计工作的影响分析

Analysis of Effect of Medical Record Home Page on the Statistical Work

目的通过监查病案首页的缺陷情况,分析缺陷原因,采取相应改进措施,从而确保医院统计数据的真实性,准确性和及时性。方法对某院2016年下半年每月住院病案首页进行随机抽查修正,将抽查情况登记并录入Excel进行归类汇总及统计分析。结果随机抽查2016年下半年住院病案共4 554份,其中有缺陷的共1 004份,错误率为22.05%。结论通过规范人员培训,改变编码模式,加强信息建设等措施可以有效提高病案首页质量,确保统计源头数据准确,从而提高医疗信息统计质量。

Objective To analyze the defect causes by monitoring the defect situation of medical records home page and adopt the corresponding improvement measures thus ensuring the authenticity,accuracy and timeliness of hospital statistical data.Methods The monthly hospitalization medical record home pages were randomly extracted and rectified from June to December 2016,and the sampling test situation was registered and input into Excel for summarization and statistical analysis.Results 4 554 pieces of hospitalization medical records from June to December 2016 were randomly extracted in total,including 1 004 defective pieces,and the error rate was 22.05%.Conclusion We can effectively improve the medical record home page quality and ensure the accuracy of statistical source data by standardizing the personnel training,changing the code mode and enhancing the information construction measures thus improving the medical information statistical quality.