住院病案首页填写项目权重体系的建立

The Establishment of a Weighting System for Filling in Items on the Homepage of Inpatient Medical Records

随着我国医疗领域的逐渐增强,与以往相比,我国医疗的整体运作模式以及治疗手段实现了全面增长,对患者可以完成有效治疗,以保障整体的治疗效果可以符合患者的治疗要求。其中,在住院病案首页填写项目权重体系当中,我国实行了相应的改进措施,以保障其整体的填写质量。在改进中,以控制并按首页质量为综合目标,通过了比较以及分析模式,对病案首页项目完成有效的分类并赋予相关领域的权重,通过评比打分的方式,对其分值以及整体结果完成综合计算。通过计算,可以得知病案首页各类项目对于其整体的首页质量控制具有明显的重要性。对于手术操作以及其后续的诊断、治疗费用等核心项目,其分值分别为7.8、7.12以及6.39。由此可见,此分值是关系到病案首页质量的关键性因素,必须有效落实,以保障整体指标的有效。同时,也可以对病案首页质量进行有效的考量,分析其整体的结果,保证其更有客观性以及科学性。在病案首页填写质量当中,进行质控检查,并针对其改进措施前后的整体效果进行有效评价。在改进模式分析中,可以得知其整体的首页填写缺陷率较以往相比,实现了全面降低。

With the gradual enhancement of our country's medical field,compared with the past,the overall operation mode and treatment methods of our country's medical treatment have achieved overall growth,and effective treatment can be completed for patients to ensure that the overall treatment effect can meet the treatment requirements of patients.Among them,in the weighting system of filling items on the first page of hospitalized medical records,our country has implemented corresponding improvement measures to ensure the overall filling quality.In the process of improvement,the comprehensive goal is to control and follow the quality of the homepage,through the comparison and analysis mode,complete the effective classification of the medical record homepage items and assign weights to the related fields,through the way of scoring,the scores and the comprehensive calculation of overall results were completed.Through calculation,it can be known that the various items on the front page of the medical record are of obvious importance to the overall quality control of the front page.For core items such as surgical operation and its follow-up diagnosis and treatment costs,the scores were 7.8,7.12 and 6.39 respectively.It can be seen that this score is a key factor related to the quality of the first page of the medical record and must be effectively implemented to ensure the effectiveness of the overall index.At the same time,the quality of the first page of the medical record can also be effectively considered,and the overall result can be analyzed to ensure that it is more objective and scientific.Fill in the quality in the first page of the medical record,conduct quality control inspections,and effectively evaluate the overall effect before and after the improvement measures.In the improvement mode analysis,it can be seen that the overall homepage filling defect rate has been reduced compared with the past.