妇产专科医院住院病案首页填写质量分析

Quality Analysis of the Home Page of Medical Records in the Maternity Hospital

目的对某三级甲等妇产专科医院住院病案首页填写质量进行分析并提出改进方案,为进一步提高妇产专业住院病案首页数据质量提供参考依据。方法采用分层随机抽样法,抽取2018年1月1日-2019年12月31日的出院病案4677份进行住院病案首页质控,对评分等级、缺陷指标类别、缺陷项目进行比率分析。结果抽检住院病案首页中,存在缺陷的3240份,总体缺陷率为69.28%,平均得分98.04分。按项目统计,诊疗信息缺陷率68.07%,基本信息缺陷率25.76%,过程信息缺陷率6.16%。按指标类别统计,A类缺陷率34.73%,B类缺陷率16.83%,C类缺陷率14.40%,D类缺陷率34.04%。结论住院病案首页中诊疗信息、A类指标和D类指标缺陷率最高,主要原因有产科诊断及编码的复杂性等客观因素、医务人员因素和管理因素。应加强住院病案首页系统信息化建设、对医务人员开展针对性培训、完善住院病案首页质控体系等措施,进一步提高妇产专业住院病案首页数据质量,为三级公立医院绩效考核和DRGs工作打下坚实基础。

Objective To analyze the quality of the home pages of medical records of a third class maternity hospital and put forward the improvement plan,so as to provide a reference for further improving the quality of filling in the home page of medical records in maternity specialty.Methods Using stratified random sampling method,4,677 medical records from 2018 to 2019 were selected for home page quality control and the ratio of rating,defect index category and defect item were respectively analyzed.Results there were 3240 cases with defects in the home page of the medical records,the overall defect rate was 69.28%and the average score was 98.04,the defect rate of diagnosis and treatment information was 68.07%,the basic information was 25.76%,and the process information was 6.16%counted by project.The defect rate of class A was 34.73%,class B was 16.83%,class C was 14.40%,and class D was 34.04%counted by indicator category.Conclusion The highest three defect rates of home pages were diagnosis and treatment information,class A items and class D items.The main reasons are objective factors such as the complexity of obstetric diagnosis and coding,medical staff factors and management factors.We should strengthen the information construction of the home page system,carry out targeted physician training,and improve the home page quality control system to further improve the data quality of the home page of maternity medical records,so as to lay a solid foundation for the performance appraisal and DRGs work of the three-level public hospitals.