办公自动化在病案首页手术相关数据质量管理中的运用

Application of office automation in the quality management of operation related data on the front page of medical records

目的分析办公自动化(OA)在病案首页手术相关数据质量管理中的运用效果,为创新病案首页手术相关信息管理模式提供实践依据。方法2018年9月到2019年8月(第一阶段)某院全院13004份病案首页手术相关信息资料为对照组,采用常规管理方法;2019年9月到2020年8月(第二阶段)该院全院13306份病案首页手术相关信息资料为实验组,在常规管理方法基础上,加用病案管理OA移动端。对比2组病案首页手术缺失率、病案首页手术/操作编码准确率、手术/操作数据准确率(手术人数、介入手术人数、微创手术人数、重点手术人数、手术/操作级别的准确率)、医务人员对病案首页手术信息调取服务的满意度。结果实验组病案首页手术缺失率低于对照组,实验组病案首页手术编码准确率、手术/操作数据准确率高于对照组,实验组医务人员对手术信息调取的满意度高于对照组,2组差异具有统计学意义(P<0.05)。结论OA在病案管理中的应用,可降低病案首页手术缺失率,提高病案首页手术编码准确率及手术/操作数据准确率,改善医务人员对手术相关数据提取服务的满意度,为医院信息化发展提供更准确、全面、高效的手术信息化服务,值得推广应用。

Objective To analyze the application effect of office automation(OA)in the quality management of operation related data on the front page of medical records,and to provide practical basis for the innovation of operation related information management mode on the front page of medical records.Methods From September 2018 to August 2019(the first stage),13004 cases of operation related information on the front page of medical records were selected as the control group,and the routine management method was used;from September 2019 to August 2020(the second stage),13306 cases of operation related data on front page of medical records in the whole hospital were taken as the experiment group,and on the basis of conventional management methods,OA mobile terminal of medical record management was added.The two groups were compared on the missing rate of surgery on the first page of medical records,the accuracy rate of surgery/operation coding on the first page of medical records,the accuracy rate of surgery/operation data(the number of surgeries,the number of interventional surgeries,the number of minimally invasive surgeries,the number of key surgeries,the accuracy rate of surgery/operation level),and the satisfaction of medical staff on the operation information retrieval service on the front page of medical records.Results The missing rate of surgery on the first page of medical records in the experimental group was lower than that in the control group,the accuracy rate of surgery coding and surgery/operation data on the first page of medical records in the experimental group was higher than that in the control group,and the satisfaction of medical staff on operation information retrieval in the experimental group was higher than that in the control group,with statistical significance(P<0.05).Conclusion The application of OA in medical record management can reduce the missing rate of surgery,improve the accuracy of surgery coding and surgery/operation data on the front page of medical records,improve the satisfaction of medical staff on operation related data extraction service,and provide more accurate,comprehensive and efficient operation information service for the development of hospital information,which is worthy of popularization and application.