绩效考核背景下公立医院病案首页数据填报现状研究

Research on the present situation of the first page data filling of medical records in public hospitals under the background of performance appraisal

目的分析乐山地区参加公立医院绩效考核的各医院病案首页填报管理情况和数据质量,针对存在的问题提出建议。方法对14家医院随机抽取2021年出院病案各50份,按照《住院病案首页数据质量评分标准》逐份进行质控,分析病案首页数据缺陷,同时定量与定性相结合调查病案首页数据填报流程和病案管理情况。结果质控病案中存在病案首页缺陷的占45.3%;影响绩效考核监测指标的病案首页数据中入院病情、诊断和编码、手术操作及编码、切口愈合等级数据的缺陷占比较高;病案首页数据采集、质控和接口上报等环节存在薄弱点。结论各医疗机构应进一步梳理病案首页数据填报各环节问题,针对数据缺陷和薄弱环节加强质控考核和建设管理。

Objective To analyze the management and data quality of the first page of medical records of public hospitals in Leshan,and put forward some suggestions for the existing problems.Methods Fifty medical records of discharged patients in 2021 were randomly selected from 14 hospitals,and quality control was carried out one by one according to the"data quality scoring standards for the first page of inpatient medical records",data defects of the first page of medical records were analyzed,and the data filling process and management of medical records on the first page of medical records were investigated by combining quantitative and qualitative methods.Results Defects in quality control medical records accounted for 45.3%;among the data on the first page of medical records that affected performance assessment monitoring indicators,the defects of admission condition,diagnosis and code,surgical operation and code,and incision healing grade accounted for a relatively high proportion.There were weak points in data collection,quality control and interface reporting on the first page of medical records.Conclusion All medical institutions should further sort out the problems in all links of data filling on the home page and strengthen quality control assessment and construction management for data defects and weak links.