运用帕累托分析法结合信息技术在提高病案质量的效果分析

Application Effect of Pareto Analysis with Information Technology on Improving the Quality of Medical Record

目的通过帕累托分析法(Pareto analysis)筛选出病案首页缺陷的主要因素,通过信息系统针对性进行监控管理,提升病案首页质量。方法以随机抽样方法分别抽取2016年1月-2016年12月我院未使用信息技术前的病案首页1000份作为对照组,检查出有缺陷的病案首页栏320项,并通过帕累托分析法筛选主要缺陷,2017年1月-2017年12月运用信息技术后的病案首页1000份作为研究组,检查出有缺陷的病案首页栏170项,比较信息技术使用前后病案首页信息填写的质量。结果采用信息技术后,研究组的基本信息缺漏率、辅助检查栏漏填率、临床路径错填率、出院情况错误率均明显低于对照组,对比P<0.05,有统计学意义。结论采用信息技术加强对病案首页填写的管理,能够提升病案首页填写的质量以及准确性,但对于病案首页质量的管理应体现持续改进,通过帕累托分析法结合信息技术形成闭环管理,持续提升病案首页质量。

Objective To use Pareto analysis to screen out the main factors of defects in the front page of medical records,to monitor and manage medical records by information system so as to enhance the quality of the front page of these records. Methods A random sampling was used to select 1,000 front pages of medical records as control group from January2016 to December 2016 in our hospital. 320 items of defective home pages of medical records were found,and the main defects were screened out by Pareto analysis. 1000 copies of the home pages of medical records from January 2017 to December2017 were selected as the research group and 170 items in the home page of medical records were found defective. Meantime,the information quality of the home page was compared between pre-and post-use of information technology. Results After using information technology,the missing rate of basic information and auxiliary check,the error rate of clinical path and of discharge for the research group were significantly lower than those of the control group statistically（ P 〈0. 05）. Conclusion The use of information technology can further manage to fill out the home page of medical records in order to improve the quality and accuracy of the home page. But the management of the quality for the home page should also be constantly enhanced. Closed-loop management should be implemented better by combining information technology so as to improve the quality of the home pages incessantly.