病案完整性对住院病案首页质量的影响

The Influence of the Integrity of Medical Records on the Quality of the Front Page of Inpatient Medical Records

目的通过加强对住院病案后滞单页的管理,在提高住院病案完整性的同时减少住院病案首页信息的二次修改和补录量,以确保住院病案首页质量。方法采集北京市某三甲综合医院加强病案后滞单页管理前后2018年11月1日-2019年1月31日和2019年11月1日-2020年1月31日的后滞单页量和住院病案首页修改例数,选取出院人数较多的18个病房进行加强管理前后对比分析。使用SPSS19.0统计软件,对加强住院病案后滞单页管理前后产生后滞单页例数和住院病案首页修改例数分别做卡方检验,住院病案后滞单页例数与住院病案首页修改例数做相关性分析,在P<0.01时具有统计学意义。结果加强管理后后滞单页例数从5039例减少到3260例,病案首页修改例数随之从2836例减少到1773例,卡方检验,P值接近于0,改革前后2组数据有显著性差异,后滞单页例数和病案首页修改例数成正相关。结论通过加强对住院病案后滞单页的一系列管理,可以提高病案的完整性和ICD编码的首次录入质量,从而提高住院病案首页的质量。

Objectives By strengthening the management of the single page of the inpatient medical record, we could not only improve the integrity of the inpatient medical record, but also reduce the secondary modification and supplement of the information on the front page of the inpatient medical record, so as to ensure the quality of the first page of the inpatient medical record. Methods The number of delayed single pages and the number of modified cases on the front page of medical records from November 1st, 2018 to January 31st, 2019 and from November 1st, 2019 to January 31st, 2020 before and after strengthening the single page management of medical records in a Three A and Tertiary Hospital in Beijing were collected. 18 wards with large number of discharged patients were selected for comparative analysis before and after strengthening the management. Spss19.0 statistical software was used to do chi square test on the number of cases of delayed single page before and after strengthening the management of single page of inpatient medical record and the number of cases of modifying the front page of medical record respectively. The correlation analysis was made between the number of cases with delayed single page and the number of modified cases on the front page of medical record, which had statistical significance when P<0.01. Results After strengthening the management, the number of delayed single page cases decreased from 5039 cases to 3260 cases, and the number of front page modification cases decreased from 2836 cases to 1773 cases. Chi square test showed that P value was close to 0. There was significant difference between the two groups of data before and after the reform, and the number of delayed single page cases was positively correlated with that of home page modification. Conclusions The integrity of medical records and the quality of the first entry of ICD code could be improved by strengthening the management of the single page of the inpatient medical record, so as to improve the quality of the front page of the inpatient medical record.