公立医院绩效考核的病案首页数据质量现状分析

Analysis and Countermeasures of Data Quality on the Front Page of Medical Records Based on Performance Assessment in Public Hospitals

目的实现对内提高病案书写质量、对外提高医院质量监测系统数据上报质量,并为二级医院或病案信息化水平较落后的医疗机构病案首页数据上报工作提供参考。方法通过医院质量监测系统上报的错误反馈,分析2018—2020年病案首页数据上报中的缺陷问题,对比3年病案首页数据首次上报的缺陷率浮动情况,并总结在数据复核过程中实施的相应对策。结果2018—2020年的病案首页首次上报错误率逐年下降,同时各项问题错误均逐年下降。结论通过从病案书写、病案质控角度和信息系统3个方面共同改善,可以有效提高病案质量,提升病案首页数据上报准确率。

Objective Improve the quality of medical case writing internally,promote the quality of HQMS data reporting externally,and provide a reference for the data reporting of the front page data of medical institutions with the backward level of case informatization in secondary hospitals or medical institutions.Method Through the error feedback of the HQMS reporting system,the defect problems in the 2018—2020 case home page data report are analyzed,the defect rate fluctuations reported for the first time in the three-year case home page data are compared,and the corresponding countermeasures implemented in the data collation process are summarized.Result The error rate of the first report of the first page of the medical case in the three years of 2018—2020 has decreased year by year,and the error rate of various problems has decreased year by year.Conclusion By jointly improving from the perspective of case writing,case quality control and information system,the quality of the case can be effectively improved and the accuracy of the data reporting on the first page of the case can be improved.