住院病案首页填写质量改进效果分析

Analysis of the Improvement Effect of the Front Sheets of Medical Records

目的了解制定并施行病案首页填写的改进措施后,病案首页填写质量的改进效果。方法随机抽取9个DRGs试点科室2017年1月1日-2017年6月30日出院病案共676份,对病案首页填写质量进行质控检查,对比2016年同期出院的583份病案首页,进行改进措施实施前后的效果评价。结果 2017年病案首页填写缺陷率为11.7%,较2016年降低了44.0%,同时各类型缺陷的发生率较2016年明显减少。结论采取病案首页填写质量责任人、加强病案首页书写培训、加强病案首页专项绩效考核等改进措施后,病案首页填写质量明显提升。

Objective To learn the improvement effect of first page of medical records after formulating and implementing improvement measures. Method 676 copies of the medical records of the 9 DRGs pilot departments were selected randomly from January to June 2017, and compared to 583 front sheets of medical records in 2016, to evaluate the improvement effect. Results From January to June of 2017, the vacancy rate was11.7%, which was 44.0% lower than in 2016, while the incidence of each type of defect was significantly lower than that of 2016. Conclusion The improvement measures taken by a hospital are effective, and the quality of the first page of the cases is significantly improved.