信息化建设对病案首页信息质量的作用

Effect of Informatization Construction on the Data Quality in Front Page of Medical Records

目的探讨信息化建设对病案首页信息质量的作用。方法对某院2016年1月1日-2017年12月31日期间病案管理科43852份出院患者病案首页资料进行质量分析,采用数字随机法抽取2016年19743份病案信息(改进前)和2017年24 109份病案信息(改进后)进行病案首页填写质量评价。结果病案首页信息采集流程不流畅、项目填写不规范、患者基本信息掌握不完善是导致病案首页质量缺陷的主要原因。43852份病案首页中12 689份(29.61%)病案首页信息存在基本信息缺陷;2017年总缺陷率14.58%显著低于2016年总缺陷率46.47%(P<0.05),经改进后2017年基本信息错误率(10.46%)与2016年(34.72%)相比具有显著差异(P<0.05),而住院过程信息漏项不同年限改进对比差异具有统计学意义(2.56%vs6.36%,P<0.05)。结论完善病案首页信息相关表单结构,运用信息化病案系统校验,提高病案首页信息完整性,降低缺陷率,有利于促进病案首页信息质量的有效利用。

Objective To investigate effect of informatization construction to the data quality in front page of medical records. Methods The quality in front page of medical records among 43852 discharged patients in one hospital from January 2016 to December 2017 was analyzed. 19743 cases in 2016（pre-improvement） and 24109 cases in 2017（post-improvement） were selected according to the random number table method. Results The mainly defects content of medical records front page included non-smooth collection process, nonstandard filling and incomplete mastery of basic information. There were 12689（29.61%） basic information defects in the front page of the 43852 medical records. The total defect rate was 14.58% in 2017, which was lower than 46.47% in 2016（P〈0.05）. The error rate of basic information decreased from 34.72% in 2016 to 10.46% in 2017（P〈0.05）. The defect rate hospitalization process information had also been ameliorated in 2017（2.56% vs 6.36%, P〈0.05）. Conclusions The optimization of form structure, verification of medical records system as well as the improvement of the information integrity were conducive to the prompting and utilization of the information quality, so as to reduce the defect rate.