基于三级公立中医医院绩效考核的病案首页质控分析

Analysis on the Quality Control of the Front Page of Medical Records Based on the Performance Appraisal of the Third-grade Public Chinese Medicine Hospital

目的统计分析基于三级公立中医医院绩效考核的某三甲公立中医医院住院病案首页质控问题,并且提出改进的措施。方法选取2020年1月1日-2020年8月31日某三甲公立中医医院总计28717份出院病案首页进行质控,并将出现问题的病案首页1328份进行分类统计分析。结果统计时间域内出现问题的病案份数占总出院病案份数的4.62%,并且1328份中医住院病案首页出现问题总频数为1402。其中首页数据一致性问题占比0.50%,首页填报完整性问题占比36.38%,首页填报规范性问题占比44.93%,首页数据逻辑性问题占比13.26%,以及其他类问题占比4.92%。结论信息录入人员的定期培训,信息系统的完善改进以及质控管理的制度强化能有效提高中医住院病案首页质量,有利于三级公立中医医院绩效考核工作开展。

Objectives A statistical analysis was made on the quality control of the front page of inpatient medical records of a Three A and Tertiary Public Traditional Chinese Medical(TCM)hospital based on the performance assessment of the third-grade public TCM hospital,and improvement measures were proposed.Methods From January 1st,2020 to August 31st,2020,a total of 28717 front pages of discharge medical records in a Three A and Tertiary Public TCM hospital were selected for quality control,and 1328 front pages of medical records with problems were classified and statistically analyzed.Results The number of medical records with problems in the time domain accounted for 4.62% of the total discharged medical records,and the total frequency of problems in the front page of 1328 TCM inpatient medical records was 1402.Among them,the consistency of the data in the front page accounted for 0.50%,the completeness of the report in the front page accounted for 36.38%,the standardization of the report in the front page accounted for 44.93%,the logic of the data in the front page accounted for 13.26%,and other problems accounted for 4.92%.Conclusions Regular training of information inputting personnel,improvement of information system and strengthening of quality control and management system could effectively improve the quality of the front page of TCM inpatient medical records,which was conducive to the performance assessment of third-grade public TCM hospitals.