基于质量缺陷分析的针对性管理在住院病案首页填写中的应用效果

Application effects of targeted management based on quality defect analysis in filling in the front page of inpatient medical records

目的:分析基于质量缺陷分析的针对性管理在住院病案首页填写中的应用效果。方法:回顾性分析2022年1—6月3276份未实施基于质量缺陷分析的针对性管理的住院病案为实施前,同时分析2022年7月至2023年7月3513份实施基于质量缺陷分析的针对性管理的住院病案为实施后。比较实施前后不同类型病案首页项目缺陷检出率、各科室及不同人群特征病案首页填写质量缺陷检出率。结果:实施后项目填写不全、疾病编码不规范及病案首页项目缺陷总检出率均低于实施前,差异有统计学意义(P<0.05);实施后呼吸内科、消化内科病案首页项目缺陷总检出率低于实施前,差异有统计学意义(P<0.05);实施后,男性、女性、学历为专科、职称为住院医师、主治医师的首页项目缺陷总检出率均低于实施前,差异有统计学意义(P<0.05)。结论:基于质量缺陷分析的针对性管理应用于住院病案首页填写可降低病案首页项目缺陷检出率、科室及不同人群特征病案首页填写质量缺陷检出率。

Objective:To analyze application effects of targeted management based on quality defect analysis in filling in the front page of inpatient medical records.Methods:A retrospective analysis was performed on 3276 inpatient medical records before implementation of the targeted management based on the quality defect analysis from January 2022 to June 2022 and they were set as before implementation,and 3513 inpatient medical records after implementation of the targeted management based on the quality defect analysis from July 2022 to July 2023 were analyzed and they were used as after implementation.The detection rate of different types of medical record homepage item defects before and after implementation,and the detection rate of medical record homepage filling quality defects in different departments and different population characteristics were compared.Results:After the implementation,the detection rates of incomplete item filling and non-standard disease coding,and the total detection rate of the medical records front page defects were lower than those before the implementation,and the differences were statistically significant(P<0.05).After the implementation,the total detection rate of defects on the front page of medical records in departments of respiratory medicine and digestive medicine was lower than that before the implementation,and the difference was statistically significant(P<0.05).Further,after the implementation,the total detection rate of item defects on the home page of male,female,specialist,resident and attending physician was lower than that before the implementation,and the difference was statistically significant(P<0.05).Conclusions:The application of targeted management based on the quality defect analysis in the filling in front page of inpatient medical records can reduce the detection rate of item defects in the front page of medical records,and the detection rate of quality defects in the front page of medical records of different departments and different population characteristics.