高质量发展视角下住院病案首页质控体系的应用效果分析

Analysis of the application effectiveness of the inpatient medical record front page quality control system from the perspective of high-quality development

目的探讨住院病案首页智能化质控与人工质控相结合的质控体系的应用效果,并分析住院病案首页填写缺陷的原因及改进措施。方法以智能化病案首页质控系统上线时间为节点,选取上线前2022年1月1日-2022年6月30日住院病案作为对照组研究对象,上线后2023年1月1日-2023年6月30日住院病案作为观察组,对比分析两组住院病案首页填写缺陷情况。结果住院病案首页填写缺陷缺陷问题共分为17类,通过建立住院病案首页质控体系,观察组住院病案首页填写总体缺陷率(4.76%)较对照组(11.63%)下降6.87个百分点,各类问题缺陷率均有不同程度的下降。按首页填写问题缺陷率下降程度降序排序,下降明显的前三类缺陷问题依次是手术及操作漏填、主要诊断选择错误、其他诊断漏填,经过χ^(2)检验,P<0.05,统计数据差异有统计学意义。结论智能化质控系统与人工质控相结合的质控体系可显著提升住院病案首页质量,但仍需加强临床科室培训、住院病案首页绩效考核、信息化建设,持续确保住院病案首页质量的持续螺旋上升,促进公立医院高质量可持续发展。

Objective To explore the application effectiveness of the combined intelligent quality control and manual quality control system for inpatient medical record front pages,and to analyze the reasons for defects in filling out the front page of inpatient medical records and improvement measures.Methods Using the time when the intelligent medical record front page quality control system went online as the node,we selected inpatient medical records from January 1,2022,to June 30,2022,as the control group,and inpatient medical records from January 1,2023,to June 30,2023,as the observation group.We compared and analyzed the situation of defects in filling out the front page of inpatient medical records between the two groups.Results Defects in filling out the front page of inpatient medical records were divided into 17 categories.By establishing the inpatient medical record front page quality control system,the overall defect rate of filling out the front page of inpatient medical records in the observation group(4.76%)decreased by 6.87 percentage points compared to the control group(11.63%),and the defect rates of various categories decreased to varying degrees.According to the descending order of the decrease in defect rate of front page filling,the top three defect categories with significant decreases were omitted surgeries and procedures,incorrect selection of primary diagnoses,and omitted other diagnoses.The differences in statistical data were statistically significant(P<0.05)based on the χ^(2) test.Conclusion The combination of an intelligent quality control system and manual quality control system can significantly improve the quality of inpatient medical record front pages.However,it is still necessary to strengthen training in clinical departments,performance assessment of inpatient medical record front pages,and information construction to continuously ensure the sustained upward spiral of the quality of inpatient medical record front pages and promote the high-quality and sustainable development of public hospitals.