我院病案首页质控体系的建立与应用效果评价

Establishment and application of a quality control system for the home page of medical records in our hospital

目的探讨和完善我院病案首页质控体系,提高病案首页信息质量。方法采取普查和抽样检查相结合的方式进行质控,对质控效果采用x^2检验。结果临床医生常见错误为主要诊断错误和主要手术填写错误,与2017年同期相比,2018年医生编码错误率明显下降;2018年科室编码员编码错误率与2017年同期相比,所有编码问题的错误率明显下降,主要诊断选择错误、其他诊断漏填、错填、主要手术选择错误与2017年同期相比均明显降低;2018年医生首页填写错误率与2017年同期相比也明显下降,差异均有统计学意义(P<0.05)。结论应继续加强对临床医生首页填写和编码知识的培训,以提高病案统计科编码员和录入员的专业能力。

Objective To improve the quality control system of the home page of medical records in our hospital and the quality of information recording.Methods The quality control was carried out by both general and sampling surveys.Statistical analysis was performed using the Excel tables.The effectiveness of quality control was analyzed by Chi-squared test.Results The common mistakes made in filling and ticking the items of medical record by clinicians were incorrect input of main diagnosis and main surgery.Compared with the situations in the same period in 2017,the error rate decreased significantly among clinicians in 2018(P<0.05).In 2018,the coding error rate of department code programmers was significantly lower than that of the same period in 2017.The rates of all coding errors including incorrect input of main diagnosis,missed and wrong data filling of other diagnoses,incorrect ticking of main surgical procedures were significantly decreased compared with those in the same period in 2017(all P<0.05).The rate of filling errors on the home page by clinicians in 2018 significantly decreased compared with that in 2017(except for the nationality code)(P<0.05),and the skill of entry clerks was also markedly improved.Conclusion Training on the filling and coding of items on the home page of medical record should be strengthened to improve the professional competence of clinicians,code programmers,and entry clerks.