某市公立医院与民营医院住院病案首页质量分析

Quality Analysis of In-patient Medical Records of Public and Private Hospitals in a City

目的通过分析某市公立医院和民营医院住院病案首页数据质量,对比其缺陷率差异并找出差异主要原因,为提高某市住院病案首页填写质量提供参考。方法以全市40家公立医院和民营医院2019年1月1日-12月31日出院患者的住院病案首页为研究对象,随机抽取700份住院病案,按照住院病案质量有关标准对其首页进行质控,使用SPSS22.0软件分别对两类医院住院病案首页中四大信息的缺陷率进行统计学分析,并将具有统计学意义部分的主要缺陷项目进行对比。结果该市住院病案首页缺陷率最高的是费用信息(38.86%),最低的是基本信息(2.60%)。民营医院的总体缺陷率高于公立医院(χ^(2)=9.105,P<0.01),住院信息缺陷率低于公立医院(χ^(2)=7.930,P<0.01),诊疗信息缺陷率(11.40%)高于公立医院(8.24%)(χ^(2)=40.793,P=0.000),基本信息与费用信息方面缺陷率差异无统计学意义。手术操作和疾病诊断名称及编码、费用信息、签字类信息等项目的填写缺陷是该市住院病案首页缺陷的主要原因。结论该市民营医院和公立医院住院病案首页填写缺陷差异主要体现在总体质量、住院信息和诊疗信息方面。通过加强人员培训及信息化建设提高民营医院及公立医院主要手术操作、疾病诊断名称及编码等项目的填写正确率是该市提高住院病案首页数据质量的工作重点。

Objectives This paper analyzed the data quality of the front page of inpatient medical records of public and private hospitals in a city,compare the difference of their defect rates and find out the main reasons,so as to provide reference for improving the front page quality of the medical records in this city.Methods The front page of inpatient medical records from 40 public and private hospitals in this city from January 1st,2019 to December 31st,2019 was selected as the research object,in which 700 medical records were randomly selected and quality-controlled according to the relevant standards of medical records.SPSS22.0 software was used to analyze the defect rates of the four major information in the front page of the two types of hospitals respectively,and the major defect items with statistical significance were compared.Results The highest defect rate item in the front page of inpatient medical records in the city was cost information(38.86%)and the lowest item was basic information(2.60%).The overall defect rate in private hospitals was higher than that in public hospitals(χ^(2)=9.105,P<0.01),among which,the defect rate in hospitalization information was lower than that in public hospitals(χ^(2)=7.930,P<0.01),and the defect rate in treatment information(11.40%)was higher than that in public hospitals(8.24%)(χ^(2)=40.793,P=0.000).The difference of the defect rate between basic information and cost information was not statistically significant.The main reasons for the defects in the front page of inpatient medical records were the filling in defects in the name and code of operation and disease diagnosis,cost information and signature information.Conclusions The difference of inpatient records on the front page between private hospitals and public hospitals was mainly reflected in the overall quality,inpatient information and diagnosis and treatment information.By strengthening personnel training and information construction,improving the accuracy of main operation,disease diagnosis name and code in private and public hospitals was the focus of this city’s work to improve the data quality of the front page of inpatient medical records.