基于自主研发智能审核平台的病案首页质控效果评价

Evaluation of Quality Control Effect of Medical Records Front Pages Based on Self-developed Intelligent Audit Platform

目的基于自主研发的智能审核平台实施病案首页质控并评价其效果,以期为国家公立医院考核、DRG付费等提供准确、高质量数据。方法利用自主研发的智能审核平台对我院2016年和2019年的所有住院病案首页进行质控,采用SAS9.4比较智能质控前后住院病案首页的编码缺陷及非编码缺陷情况,评价智能审核平台的质控效果。结果2016年我院病案首页编码缺陷率为15.84%,其中绝对缺陷率7.94%,相对缺陷率9.82%;非编码缺陷率为11.47%,其中绝对缺陷率12.89%,相对缺陷率0.85%。2019年我院病案首页编码缺陷率为2.43%,其中绝对缺陷率1.19%,相对缺陷率4.09%;非编码缺陷率为0.38%,其中绝对缺陷率0.47%,相对缺陷率0.1%。智能审核平台上线后,病案首页编码缺陷率降低了13.41%(χ^(2)=1335.4133,P<0.05),病案首页非编码缺陷率降低了11.09%(χ^(2)=10349.7138,P<0.05)。结论智能质控平台有效降低了我院住院病案首页编码及非编码缺陷率,从而有效促进病案首页质量提升。

Objective To implement the quality control of medical record front pages based on self-developed intelligent audit platform and evaluate its effectiveness,in order to provide accurate and high-quality data for assessment of tertiary public hospitals and DRG payment.Methods The quality control of all discharged medical record front pages in our hospital in 2016 and 2019 were carried out using self-developed intelligent audit platform.SAS9.4 was used to compare the coding defects and non-coding defects of the medical records front pages before and after intelligent quality control,and to evaluate the quality control effect of the intelligent audit platform.Results The coding defect rate of medical records front pages in 2016 was 15.84%,of which the absolute defect rate was 7.94%and the relative defect rate was 9.82%;the non-coding defect rate was 11.47%,of which the absolute defect rate was 12.89%and the relative defect rate was 0.85%.The coding defect rate of medical records front pages in 2019 was 2.43%,of which the absolute defect rate was 1.19%and the relative defect rate was 4.09%;the non-coding defect rate was 0.38%,of which the absolute defect rate was 0.47%and the relative defect rate was 0.1%.After the launch of the intelligent platform,the coding defect rate of the medical records front pages decreased by 13.41%(χ^(2)=1335.4133,P<0.05),and the non-coding defect rate of the medical records front pages decreased by 11.09%(χ^(2)=10349.7138,P<0.05).Conclusion The self-developed intelligent platform can effectively reduce the coding defect rate and the non-coding defect rate of quality control of medical record front pages in our hospital,and effectively promoting the improvement of the data quality.