计算机质控在住院病案首页手术信息管理中的应用分析

Analysis of the Application of Computer Quality Control in the Management of Surgical Information on the First Page of Inpatient Medical Records

目的 分析计算机质控在住院病案首页手术信息管理中的应用效果,提高住院病案首页手术相关质量。方法 收集2019年1月1日-2020年12月31日住院病案首页其他手术和主要手术信息,按时间顺序分为对照组、观察组。其中,2019年1月1日-12月31日随机抽取1902份住院病案首页其他手术和主要手术信息为对照组,2020年1月1日至12月31日随机抽取1911份住院病案首页其他手术和主要手术信息为观察组。对照组采取常规方法质控,观察组在对照组基础上联合计算机质控。对比两年手术相关住院病案首页合格率、其他手术及主要手术编码准确率,其他手术及主要手术漏填率,其他手术及主要手术漏填份数,其他手术漏填科室。结果 观察组手术相关住院病案首页合格率99.06%,其他手术编码准确率99.84%,主要手术编码准确率99.84%,均高于对照组,观察组其他手术和主要手术漏填率低于对照组,两组差异显著(P<0.05)。观察组其他手术漏填科室及漏填份数低于对照组。结论 计算机质控可提高住院病案首页手术相关质量,同时应加强重点科室住院病案首页管理。

Objective To analyze the application effect of computer quality control in the operation information management of the first page of inpatient medical records,and improve the operation related quality of the first page of inpatient medical records.Methods From January 1,2019 to December 31,2020,the information of other operations and main operations on the front page of medical records were collected and divided into control group and observation group in chronological order.Among them,1902 home pages of inpatient medical records from January 1 to December 31,2019 were randomly selected as the control group,and 1911 home pages of inpatient medical records from January 1 to December 31,2020 were randomly selected as the observation group.The control group was treated with routine quality control method,and the observation group was treated with computer quality control on the basis of the control group.The first page qualification rate,coding accuracy of other operations and major operations,missed filling rate of other operations and major operations,missed filling number of other operations and major operations,and missed filling departments of other operations were compared.Results The qualified rate of the first page of operation related medical records(99.06%),the accuracy rate of coding of other operations(99.84%) and major operations(99.84%) in the observation group were higher than those in the control group,and the missing filling rate of other operations and major operations in the observation group was lower than that in the control group,with significant difference between the two groups(P<0.05).The number of missing departments and missing copies in the observation group was lower than that in the control group.Conclusion Computer quality control can improve the operation related quality of the first page of inpatient medical records,and strengthen the management of the first page of inpatient medical records in key departments.