鱼骨图分析法在病案首页质量控制中的应用

Effect of Fishbone Diagram analysis on quality control of first page of medical records

目的探讨影响康复医学科住院病案首页质量的影响因素并提出改进措施。方法复查某康复专科医院康复医学科在2021年1月—6月出院的1900份住院病案首页,统计缺陷率,运用鱼骨图分析法找出住院病案首页质量的影响因素。结果1900份住院病案首页缺陷发生率为6.89%(131/1900),鱼骨图分析法找出病案首页质量的影响因素包括临床医师、康复治疗师、编码员、信息化建设、部门协同五大维度。具体包括:临床医师责任意识不足、缺乏病案专业知识;康复治疗师工作流程不完善,质控机制缺失;编码员配备不足、未熟练掌握编码规则;信息建设发展迟缓,功能局限;多个部门分割、缺少横向沟通等。结论鱼骨图分析法能够全面性、根本性分析住院病案首页质量的影响因素,针对影响因素采取改进措施,可以降低病案首页的缺陷率,提升病案首页的数据质量。

Objective To explore the factors affecting the quality of the first page of inpatient medical records in the rehabilitation departments and put forward improvement measures.Methods The first pages of 1900 inpatient medical records from January to June 2021 in the rehabilitation department of a rehabilitation hospital were reviewed.The defect rate was analyzed.The factors affecting the quality of first pages were identified by Fishbone Diagram analysis.Results The incidence of defects on the first page of 1900 inpatients medical records was 6.89%(131/1900).The factors identified by Fishbone Diagram analysis affecting the quality of the first page of medical records fell on five dimensions,i.e.,clinicians,rehabilitation therapists,coders,information construction and department coordination.Specific influencing factors were as follows:clinicians lack of responsibility and professional knowledge about medical records,imperfect work flow in rehabilitation therapists have and lack of quality control mechanism,lack of coders and not proficiency in coding rules,slow information construction development is slow and limited function,lack of cooperation by multiple departments and lack of interdepartmental communication.Conclusion The Fishbone Diagram analysis method can comprehensively and fundamentally analyze the factors affecting the quality of the first page of in-patient medical records,through which improvement measures can be found to reduce the defect rate of first page and improve the data quality.