国内中医住院病案首页质量分析与影响因素初探

Quality Analysis and Discussion on Influencing Factors of the Homepage of Medical Records in Domestic TCM Hospitals

目的通过分析国内中医住院病案首页填报质量的影响因素,探索提高中医病案首页填报质量方法。方法首先,根据数据纳入标准,从1800万份中医住院病案首页数据中筛选出3 310 872份;其次,采用SAS9.3软件及指标判定标准,分层统计性别、年龄、入院科室、住院时间、出院科室、总费用、中医临床路径、中医诊疗设备、中西医主要诊断编码指标的缺失构成比与正确构成比,从病案首页基本信息、住院基本信息、费用信息、中医特色信息、诊断手术信息5个方面概述中医病案首页填报质量;最后,通过鱼骨图法,分析影响病案首页填报质量因素,并给出可以提高病案首页填报质量方法。结果性别缺失率0.000 0%、正确率99.993 2%,年龄缺失率0.116 2%、正确率99.868 3%,入院科室缺失率1.131 9%、正确率97.818 3%,住院时间缺失率0.243 0%、正确率99.749 2%,出院科室缺失率0.522 2%、正确率97.932 6%,总费用缺失率0.419 2%、正确率97.917 2%,中医临床路径缺失率0.662 6%、正确率99.130 2%,中医诊疗设备缺失率0.000 0%、正确率99.999 8%。结论国内中医住院病案首页中基本信息、住院基本信息、费用信息、中医特色信息的填报缺失率较低、正确率较高,而中西医诊断手术、中西医主要诊断编码等信息填报缺失率较高、正确率较低。

Objective To explore the ways to improve the filling quality of homepage of inpatients’ TCM medical records through analyzing the influencing factors of the quality of homepage of medical records in domestic TCM hospitals. Methods Firstly, according to the data included in the standards, 3 310 872 copies of TCM medical records were filtered from 18 million cases. Secondly, composition ratio of missing component and correct composition ratio of gender, age, admission department, hospitalization time, LOS (length of stay), discharge department, total cost,clinical pathway of TCM, diagnosis and treatment equipment of TCM and the main diagnostic coding index of Chinese and Western medicine were analyzed by SAS9.3 software and index judgment standard. The filling quality was summarized from five aspects of the basic information, the basic information of inpatients, the cost information,the characteristic information of TCM, diagnosis of surgical information of medical records. Finally, the factors that affect the filling quality of the first page of medical records were analyzed by fishbone diagram, and the ways that can improve the filling quality of the first page of medical records were given. Results The results showed: gender (loss rate 0.0000%, accuracy 99.993 2%), age (loss rate 0.116 2%, accuracy 99.868 3%), admission department (loss rate 1.131 9%, accuracy 97.818 2%), LOS (loss rate 0.243 0%, accuracy 99.749 2%), discharge department (loss rate 0.522 2%, accuracy 97.932 6%), total cost (loss rate 0.419 2%, accuracy 97.917 2%), clinical pathway of TCM (loss rate 0.662 6%, accuracy 99.130 3%), diagnosis and treatment equipment of TCM (loss rate 0.000 0%, accuracy 99.999 8%). Conclusion The basic information, the basic information of inpatients, the cost information, the characteristic information of TCM in the homepage of medical records are with relatively low loss rate and high accuracy, while diagnosis of Chinese and Western surgical information and TCM principal diagnosis coding have higher loss rate and low accuracy rate.