住院病案首页数据管理系统效果评价

Evaluation of the Data Management System on the Front Page of Medical Record

目的 通过分析使用住院病案首页数据管理系统对住院病案首页数据质量的影响,探究提升住院病案首页数据质量的举措研究。方法 于2020年6月在武汉某医院搭建并使用住院病案首页数据管理系统,以2019年1月1日-2019年12月31日使用系统前300 096份住院病案首页和2021年1月1日-2021年12月31日使用系统后的321765份住院病案首页作为研究对象,分析住院病案首页数据在使用系统前后的完整性、逻辑性和编码合理性。结果 运用住院病案首页数据管理系统前,住院病案首页完整性、逻辑性和编码合理性错误率分别为2.00%、2.48%和1.11%,运用住院病案首页数据管理系统后,相应的错误率分别为0.04%、0.06%和0.41%,差异均具有统计学意义。结论 建立住院病案首页数据管理系统能有效提高住院病案首页数据质量,医院需推进信息化建设、有针对性地开展病案书写规范化培训,从而提高住院病案首页数据质量。

Objectives To analysis the influence of data management system on the front page of medical record and explore the way how to improve the data quality of front page.Methods The data quality management system of medical record was applied in one hospital of Wuhan in June 2020.A total of 300096 cases who came from January 1st,2019 to December 31st,2019 before system applied were regarded as control group,while 321765 cases came from January 1st,2021 to December 31st,2021 after system applied were regarded as intervention group.The influence of data management system on the integrity,logic and coding rationality of the front page were analyzed among two groups.Results After applying the data quality management system,the error rate of the front page of medical record significantly decreased from 2.00%to 0.04%for the completeness,from 2.48%to 0.06%for the logical compliance,and from 1.11%to 0.41%for the coding rationality.Conclusions The data quality management system could effectively improve the data quality of the front page of medical record.Hospital administrator needed to promote information construction and carry out targeted standardized training on medical record writing,so as to improve the data quality of front page.