公立医院绩效考核对住院病案首页数据质量的影响

Analysis on the Impacts of Quality of the Data on the Inpatient Medical Record Front Pages Based on the Performance Appraisal of a Public Hospital

目的通过分析某医院在国家公立医院绩效考核工作前后的住院病案首页数据质量情况,提出持续改进住院病案首页数据质量的措施。方法调取某院2019年1月1日-2020年12月31日的住院病案首页数据,2019年全年共有54792份住院病案首页数据、2020年全年共有47590份住院病案首页数据,在病案软件系统中全条件审核2年数据,列出错误数据明细。以2020年数据为观察组、2019年数据为对照组,分别从总体错误情况、错误类型和错误因素的角度,运用SPSS18.0软件进行统计学分析。结果总体上2019年全年住院病案首页数据错误率为38.47%,2020年全年住院病案首页数据错误率为17.28%,差异具有统计学意义。根据错误类型分析,4种错误类型的2年数据差异都有统计学意义。根据错误因素分析,病案科因素、信息科因素、财务科因素、入院处因素的2年数据差异具有统计学意义;临床填写因素的2年数据差异不具有统计学意义。结论在国家公立医院绩效考核工作后医院的住院病案首页数据总体质量有明显提升,各种类型的数据质量均有提升。临床填写的住院病案首页数据质量无显著提升,需要进一步加强对临床的培训和考核。

Objectives This study aims to put forward the measures to continuously improve the data quality of the front pages of inpatient medical records based on the analysis of the data before and after the performance appraisal of national public hospitals.Methods The front-page data in a hospital from January 1,2019 to December 31,2020 were collected,among which 54792 records were collected in 2019 and 47590 records were collected in 2020.These two-year data were reviewed in a medical record software system under all conditions to compare the data accuracy and then listed the error data details.The error types were classified into basic information,diagnosis and inpatient operation,cost information and other information errors according to the position of the error field on the front pages of the medical records.The hospital record management committee discussed and analyzed the main causes of errors and categorized the errors into groups of medical record factors,information factors,clinical filling factors,finance factors,admission factors.This study used the data in 2020 as the observation group and 2019 as the control group and used SPSS18.0 software for statistical analysis from the perspectives of overall error situation,error type and error factors.Results In general,the error rate of the front-page data of the annual inpatient medical records was 38.47%in 2019 and 17.28%in 2020,with statistically significant differences.Based on the analysis of error types,these four types of errors all showed significant differences between these two years.Based on the analysis of error factors,medical record factors,information factors,finance factors and admission factors all showed significant differences between these two years.Clinical filling factors did not show significant differences between these two years.Conclusions The data quality of the inpatient medical record front pages in a hospital had been significantly improved after the performance appraisal of national public hospitals and the quality of all types of data had improved.Further training and learning were required because there was no significant improvement in the quality of the front-page data of inpatient medical records which needed to be filled out by clinicians.