期刊文献+

住院病案首页质量考评平台的设计与应用 被引量:13

Design and Application of the Quality Evaluation Platform for Home Page of Inpatient Medical Records
下载PDF
导出
摘要 目的对通过网络直报报送的四川省住院病案首页进行系统质量控制,提高病案首页数据质量。方法基于DRGs分析过程中发现的住院病案首页数据质量问题,针对指标优化质控规则,根据行政管理要求和医疗机构改进需求进行平台功能设计,同时对病案质量从指标完整性、报送情况、合理性和疾病编码准确性等方面进行整体评分。结果改进后的病案质量考评平台可以对每一份住院病案首页进行质量评价并打分,通过两年实践,相关医疗机构上报率从95.02%上升到99.39%;评分从78.59分提至91.42分。结论基于DRGs的住院病案首页质量考评平台,规范了病案指标的填报,提高了病案质量,有助于病案信息的及时上报,为DRGs付费制度的展开奠定基础。 Objective To carry out systematic quality control on the home page of medical records directly reported through the network of Sichuan province,to improve the data quality of the home page of medical records.Methods According to the data quality problems on the home page of medical records found in the process of DRGs analysis,in view of the index to optimize the quality control rules,platform functionwas designed based on the requirements of the administrative and the medical institutions improvement.Furthermore,the quality of medical records was assessed for the overall score from the index of integrity,submitting status,rationality and the accuracy of diseases coding.Results The improved medical record quality evaluation platform could evaluate and score the quality of the home page of each inpatient medical record.After two years of practice,the reporting rate of relevant medical institutions increased from 95.02% to 99.39% with the score raising from 78.59 to 91.42.Conclusion The quality evaluation platform on the home page of inpatient medical records based on DRGs standardizes the filling of medical records indicators,improves the quality of medical records,facilitates the timely reporting of medical records information,and lays a foundation for the development of DRGs payment system.
作者 段占祺 高岚岚 杨珣 张子武 韩旭 郭小林 潘惊萍 DUAN Zhanqi;GAO Lanlan;YANG Xun(Health Information Center of Sichuan Province,Chengdu,Sichuan,610041,China;不详)
出处 《中国卫生质量管理》 2020年第3期40-42,共3页 Chinese Health Quality Management
基金 四川省科技基础条件平台项目(计划编号:2019JDPT0008) 四川省卫生和计划生育委员会科研课题(编号:17PJ463)。
关键词 病案首页 质量监测 评分模型 改进 应用 Home Page of Medical Records Quality Monitoring Scoring Model Improvement Application
  • 相关文献

参考文献5

二级参考文献43

  • 1卫生部.卫生部医管司关于开展医疗服务监管信息网络直报试点工作的通知[S].卫医管评价便函[2011]116号,2011,7.
  • 2卫生部.卫生部医管司关于开展医院质量监测评价工作的通知[S].卫医管评价便函[2012]105号,2012,6.
  • 3LL Pipino, YL, RY Wang. Data Assessment [J]. Communication of the ACM, 2002, 45 (4) :211.
  • 4Arkady M. Data Quality Assessment[M]. USA:Technics Publications, LLC. 2007.
  • 5Nicole GW, Chunhua W. Methods and dimensions of eleclronic health record data quality assessment:enabling reuse for clinical research[J]. Journal of the American Medical Informatics Association. 2013, 20 (1) :144-151.
  • 6Joyce AM, Elizabeth CW, Michelle JK, et al. Assessing the Quality of Medical and Health Data From the 2003 Birth Certificate Revision:Results From Two States[J]. National Vital Statistics Reports. 2013, 62 (2). 20.
  • 7郭默宁,陈樾鹏,刘婉如,琚文胜.北京市卫生统计信息平台建设设想[J].中国数字医学,2008,3(9):54-56. 被引量:14
  • 8许凤娟,毛静馥,李会玲.社区卫生服务机构病案管理人员现状调查[J].中国公共卫生,2008,24(11):1392-1392. 被引量:6
  • 9黄绍贤.参观学习美国医院信息化感悟和借鉴[J].中国医疗前沿,2009,4(7):138-139. 被引量:8
  • 10刘秀珠.5624份病案首页质量分析与对策[J].中国医药导报,2010,7(4):135-135. 被引量:4

共引文献55

同被引文献145

引证文献13

二级引证文献52

相关作者

内容加载中请稍等...

相关机构

内容加载中请稍等...

相关主题

内容加载中请稍等...

浏览历史

内容加载中请稍等...
;
使用帮助 返回顶部