HQMS管理措施对病案首页填写上报数据质量的作用

The Effect of HQMS Management Measures on the Quality of Data Reported in the First Page of Medical Records

目的探讨基于HQMS的管理措施对病案首页填写上报数据质量的促进作用。方法收集我院2019年1月—2020年12月期间的出院病案首页信息,其中2019年1—12月为实施常规管理措施(整改前),2020年1—12月实施基于HQMS的管理措施(整改后),统计分析对比整改前后病案首页重点手术麻醉分级填漏率以及手术并发症信息、输血反应、输液反应的填写差错率。结果整改后重点手术麻醉分级填漏为12.63%,整改后未8.51,%,前者明显高于后者(P<0.05)。整改前手术并发症信息、输血反应、输液反应差错率分别为2.13%、2.59%、0.04%,整改后分别为0.78%、1.02%、0.01%,前者明显高于后者(P<0.05)。结论在病案首页填写上实施基于HQMS的管理措施,不仅能有效地提高上报数据质量,降低填写差错率、漏填率,促使各部门更规范、准确的填写病案首页,对保证首页填写质量以及提升医院管理水平均具有非常积极的意义,值得应用。

Objective To explore the role of HQMS based management measures in improving the quality of data reported on the first page of medical records. Methods The information of the first page of discharged medical records in our hospital from January 2019 to December 2020 was collected. The routine management measures (before rectification) were implemented from January to December 2019, and the HQMS based management measures (after rectification) were implemented from January to December 2020. The filling rate of anesthesia classification and the information of operation complications were statistically analyzed The error rate of transfusion reaction and transfusion reaction. Results After the rectification, the filling rate of anesthesia grading in key operation was 12.63%, but not 8.51%, the former was significantly higher than the latter, the difference was statistically significant (P < 0.05). The error rates of operation complication information, transfusion reaction and transfusion reaction before rectification were 2.13%, 2.59% and 0.04% respectively, and those after rectification were 0.78%, 1.02% and 0.01% respectively. The former was significantly higher than the latter, with statistical difference (P < 0.05). Conclusion The implementation of management measures based on HQMS can not only effectively improve the quality of reported data, reduce the filling error rate and omission rate, but also promote the departments to fill in the front page of medical records more standardized and accurately. It has a very positive significance to ensure the filling quality of the front page and improve the average quality of hospital management.