福建省某三甲医院住院病案首页手术数据质控效果分析

Analysis on the Quality Control Effect of Surgery Data on the Front Page of Inpatient Medical Records in a Tertiary Hospital in Fujian Province

目的通过建立住院病案首页质控体系提高住院病案首页手术相关数据质量,为三级公立医院绩效考核提供规范化、标准化的高质量数据。方法采用单纯随机抽样的方法,随机抽取未建立住院病案首页质量控制体系前2020年9月1日-10月31日外科手术病案357份为对照组,建立住院病案首页质量控制体系后2021年9月1日-10月31日外科手术病案400份为观察组,对比两组主要手术操作和其他手术操作填写及编码正确率,采用卡方检验进行分析,评价质控后效果。结果观察组主要手术操作填写正确率99.5%、主要手术操作编码正确率99%、其他手术操作填写正确率99.86%、均高于对照组,P<0.05表示差异具有统计学意义,其他手术操作编码正确率质控前后对比,差异无统计学意义(P>0.05)。主要手术操作错误常见问题包括医师层面的主要手术选择错误、手术部位书写不明确、漏填手术操作,编码员层面的错编和编码过于简单;其他手术操作常见问题医师层面包括漏填、错填,编码员层面错编、多编。结论建立质控体系后手术操相关数据质量得到提升,但是仍需要完善质控措施,进一步提高手术填写完整度和编码准确率。

Objectives This study aims to provide standardized and standardized high-quality data for performance appraisal of tertiary public hospitals through improving the quality of surgery-related data on the front page of inpatient medical records by establishing a quality control system for the front page of inpatient medical records.Methods A simple random sampling method was used to randomly select 357 surgical medical records before the establishment of the quality control system on the front page of inpatient medical records from September 1st to October 31st,2020 as the control group.400 surgical medical records after the establishment of the quality control system from September 1st to October 31st,2021 were selected into the observation group.The correct rates of filling and coding of the main surgical operations and other surgical operations in the two groups were compared.Chi-square test was used to analyze and evaluate the effect after quality control.Results In the observation group,the correct rate of filling in the main surgical operation was 99.5%,the correct rate of the coding of the main surgical operation was 99%,and the correct rate of filling in other surgical operations was 99.86%,all of which were higher than those of the control group.P<0.05 indicated that the difference was statistically significant.There was no significant difference in the coding accuracy of other surgical operations before and after quality control(P>0.05).Common problems of major surgical operation errors included incorrect selection of major surgical procedures at the physician level,unclear surgical site writing,missing surgical operations,wrong coding at the coder level,and oversimplified coding.Other common problems in surgical operations include omissions and wrong fillings at the physician level,and wrong and multiple compilations at the coder level.Conclusions After the establishment of the quality control system,the quality of data related to surgical operations has been improved,but quality control measures still need to be improved to further improve the completeness of surgical procedures and the accuracy of coding.