肿瘤科病案首页填报质量分析

Analysis and Comparison of the Quality of the First Page of the Medical Records of Oncology Department

目的对某院肿瘤科住院病案首页进行质量评估,探讨提高住院病案首页数据质量的方法。方法检索肿瘤科出院患者住院病案首页数据,其中查阅2016年3月病案首页393份,查阅2017年3月病案首页418份,根据既往编目标准和国家卫计委最新制定的《住院病案首页数据管理与控制指标(2016版)》的要求对病案首页完整性和准确性进行评价和比较。结果根据既往编目标准对2016年3月与2017年3月统计分析,填报完整性指标:填报完整率分别为63.88%、69.88%;填报准确性指标:主要诊断选择正确率都为100%;主要诊断编码正确率99.75%、99.52%,主要手术及操作选择正确率分别为99.49%、99.76%,其他诊断编码正确率97.20%、99.04%,根据2016年最新编码标准重新对两年病案编码进行审核,变化最大的是,准确性指标:主要手术及操作选择正确率分别为22.65%、99.76%,其他诊断填写完整正确率分别12.47%、100%,两组数据经SPSS19.0软件用t检验进行统计分:病案首页整体填写质量稳中有升,其中2017年3月较2016年3月患者基本信息填报质量、诊疗信息有明显提析高,具有统计学意义,数据都成正态分布。结论国家最新质量评审标准对病案首页提出了更高的要求,以新标准要求,目前肿瘤科出院病案首页质量仍有提高空间,需针对重点问题继续攻克完善。

Objective To evaluate the quality of the first page of a medical record of oncology inpatient and to discuss the methods to improve the quality of the data. Methods Retrieving the medical records data of oncology inpatient, including 393 copies of first page of medical records in March 2016, 418 copies of first page of medical records in March 2017, according to the National Planning Commission recently formulated medical records datamanagement and control index（2016 Edition） requirements to evaluate and compare the completeness and accuracy on the first page of medical records. Results The complete rate of March 2016 and March 2017 were 63.88% and 69.88%; the correct rate of primary diagnosis were all 100%; the correct rate of the main diagnostic codes were 99.75 % and 99.52 %; the correct rate of main operation and operation selection were 99.49 % and 99.76 %; other diagnostic code accuracy rate were 97.20% and 99.04%; According to the 2016＇s new encoding standard, re-audited on the two year＇s medical records encoding, the correct rate of operation and operation coding was22.65%, 99.76%,and the complete accuracy of other diagnosis was 12.47%, 100%,Analysis two groups of data by SPSS 19. 0 software and t test was used for statistical analysis： The overall quality of fill in the first page is improved steadily, the basic information of patients reporting quality and medical information accuracy in March 2017 has improved obviously than that in March 2016, with statistical significance, The data are match normal distribution. Conclusion The latest national quality assessment standards has higher requirements on first page of medical record. The quality of the first page of the medical records of oncology department still has improved space with the requirements of the new standard,the key problems and key projects still needs to be improved.