电子病历在线质控系统对于提高病案首页数据质量的作用探讨

The effect of electronic medical record online quality control system on improving the data quality of the first page of medical records

目的探讨电子病历在线质控系统对于提高病案首页数据质量的作用。方法导出某院应用电子病历在线质控系统前后共5年的住院病案首页数据,并分别导入到首页数据质量检测系统和DRG分组系统中,得到首页质检结果后运用Microsoft Office Excel 2010进行整理与汇总。结果应用电子病历在线质控系统后,病案首页编码整体错误率由3.79%下降到2.64%,下降幅度达30.343%;首页质量评分均值由2014年的82.90分,逐步提升至2018年的97.59分;DR G入组率由2014年的85.16%,逐步提升到2018年的99.84%。结论电子病历在线质控系统的应用,对于持续提高病案首页数据质量有一定的积极作用,能够为医院开展DR G付费与绩效考核奠定一个坚实的数据基础,值得推广。

Objective To explore the effect of electronic medical record online quality control system on improving the data quality of the first page of medical record.Methods The home page data of inpatient medical records before and after the application of online quality control system of electronic medical records in a hospital were exported and imported into the home page data quality detection system and DRG grouping system respectively.The home page quality inspection results were obtained and then sorted and summarized by Microsoft Office Excel 2010.Results After the application of the online quality control system of the electronic medical record,the overall error rate of the first page coding of the medical record decreased from 3.79%to 2.64%,with a decrease rate of 30.343%;the average quality score of the first page gradually increased from 82.90 in 2014 to 97.59 in 2018;the enrollment rate of DRG gradually increased from 85.16%in 2014 to 99.84%in 2018.Conclusion The application of online quality control system of electronic medical records has a positive effect on improving the data quality of the front page of medical records.It can lay a solid data foundation for DRG payment and performance evaluation in hospitals and is worth promoting.