上海市某医院基于绩效考核的住院病案首页培训效果评价

Effect Evaluation of Quality Training on the Front Page Writing of Inpatient Medical Records Based on Performance Appraisal

目的通过对上海市某医院基于绩效考核为导向的住院病案首页填写培训,分析培训前后质量的变化,促进住院病案首页填写质量。方法按照随机抽样的方法抽取2018年1月1日-11月30日培训前8525份出院病案和2019年1月1日-11月30日培训后8525份出院病案,共17050份。对现住址、疾病分型、主要诊断、主要手术和操作、入院病情、其他诊断填写完整度、离院方式、是否31天内再住院计划等8项指标的情况进行质控统计。结果住院病案首页的总正确频次由培训前的30145次上升到了31789次,总错误频次由培训前的2046次下降到801次,χ^(2)=682.301,P<0.05,差异具有统计学意义。培训后8项指标分项错误次数均低于培训前,经过卡方检验,均P<0.05。低优指标和高优指标培训后均有上升。结论加强基于绩效考核为导向的住院病案首页填写质量培训,可为医院管理提供改进措施和目标,医院要重视病案首页的填写质量,共同促进医疗水平的提高。

Objectives To analyze the quality changes before and after the training on the first page of inpatient medical records based on the performance appraisal oriented training in a hospital in Shanghai,so as to promote the quality of filling in the front page of inpatient medical records.Methods 8525 discharged medical records before training from January 1st,to November 30th,2018 and 8525 discharged medical records after training from January 1st,to November 30th,2019 were selected,with a total of 17050.The current address,disease classification,main diagnosis,main operation and operation,condition of admission,completeness of other diagnosis,mode of leaving hospital,whether the plan of rehospitalization within 31 days and other 8 indicators were statistically analyzed.Results The total correct frequency of the front page of inpatient medical records increased from 30145 times before training to 31789 times,and the total error frequency decreased from 2046 times before training to 801 times,χ^(2)=682.301,P<0.05,the difference was statistically significant.After the training,the number of sub item errors of 8 indexes was lower than that before training,and the chi square test showed that all P<0.05.After the training,both the low and high excellent indexes increased.Conclusions Strengthening the quality training of the front page of medical records based on performance appraisal could provide improvement measures and goals for hospital management.Hospitals should pay attention to the filling quality of front page of medical records,and jointly promote the improvement of medical level.