基于“一动力三循环”“双质控”法提高病案首页质量

Improving the Quality of Front Page of Medical Record Based on "One Power, Three Circulation" and "Double Quality Control"

目的针对病案首页填写存在的问题进行阐述,文章首先对病案首页填写中存在的问题进行阐述,探讨应用"一动力三循环"管理模式的"双质控"法在提高病案首页数据质量及效果。方法应用"一动力三循环"医疗质量管理模式,引入"双质控"方法,即智能质控、人工质控,对病案首页填写中存在的问题进行改进,对2019年1—5月及2020年1—5月部分字段经过智能质控及人工质控后首页填写错误率进行比较。结果 2020年1—5月字段填写错误率都有所下降,智能质控及人工质控取得一定的效果,首页填写质量提高。结论应用"一动力三循环"管理模式的"双质控"法能够较实时、较全面的提高病案首页填写质量,减少病历回退返改的次数,提高医务人员书写病历的效率,最终提高病案首页数据质量,真正发挥病案首页数据的作用。

Objective To elaborate the problems existing in the filling of the first page of medical records. Firstly, this paper expounds the problems existing in the filling of the first page of medical records, and discusses the application of the "double quality control" method of the "one power and three cycles" management mode in improving the data quality and effect of the first page of medical records. Methods Applied "one power and three circulation" medical quality management mode, introduced "double quality control" methods, namely intelligent quality control and manual quality control, improved the problems existing in filling in the front page of medical records, and compared the error rate of filling in the front page of some fields from January to May 2019 and January to May 2020 after intelligent quality control and manual quality control. Results From January to May 2020, the error rate of field filling decreased, intelligent quality control and manual quality control achieved certain results, and the filling quality of home page improved. Results From January to May in 2020, the error rate of field filling decreased, intelligent quality control and manual quality control achieved certain results, and the filling quality of home page improved. Conclusion The application of "double quality control" method of "one power and three circulation" management mode can improve the filling quality of the first page of medical records in real time and comprehensively, reduce the number of times of returning and modifying medical records, and improve the efficiency of medical staff in writing medical records. Finally, improve the quality of medical record home page data, and really play the role of medical record home page data.