无锡地区二级医院医疗质量评价体系建设和应用

Construction and Application of Medical Quality Evaluation System of Second-level Hospital in Wuxi

目的:利用标准化病案首页数据采集平台,建立医院病案首页质量监测的标准化应用体系,动态掌握医院病案首页数据质量。方法:通过建立病案首页信息上报系统,实施对无锡市二级医院的病案首页进行持续性监控,对数据进行持续系统性分析,对住院病案进行更有针对性的质量控制和质量管理。结果:建立省内首个二级医院病案首页数据库,开展病案首页质量室间对比分析,提供完整的病案首页质量分析报告,建立病案首页质量分析评估体系。结论:医院病案首页质量监测的标准化应用体系为基层二级医院提供完善的病案首页质量分析数据,指导基层医院开展病案首页质量管理,变定性管理为定量管理,取得明显的效果。

Objective ： To establish a standardized application system for the quality monitoring of hospital medical records by using the standard data collection platform on the front page of medical records, and dynamically graspe the data quality results of the hospital medical records. Methods ： hnplement the continuous monitoring of the medical records of the second-level hospitals in the city by establishing the information reporting system on the home page of the medical records, and carry out continuous systematic analysis of the data to conduct more targeted quality control and quality management of the inpatient medical records. Results ： The first database of the second-level hospital medical records in the province was established, and the comparative analysis of the quality of the medical records on the front page of the medical records was carried out. Provide a complete medical record page quality analysis report. Estab- lish a quality analysis and evaluation system for the medical record home page. Conclusion ： The standardized application system for the quality monitoring of the hospitaFs medical records is the comprehensive quality data of the medical records provided by the primary hospitals. It guides the primary hospitals to carry out the quality management of the medical records, and the variable management is quantitative management, which has achieved obvious results.