基于信息技术的住院病案首页质量评估

Quality Evaluation of Inpatient Medical Record Front Page Based on Information Technology

目的采用信息技术对住院病案首页数据进行评估,为提高住院病案首页数据质量提供参考。方法2023年1月1日-2023年6月30日按照疾病和手术编码基本规则、主要诊断选择原则、公立医院绩效考核数据上报规范设置校验规则,系统对不规范的住院病案首页信息自动提示详细的错误,再由质控医师和编码员逐一核对、整改。结果51185份病案中,有15369份病案存在缺陷,其中内科缺陷率为28.46%,外科缺陷率为31.30%,差异有统计学意义(χ^(2)=48.36,P<0.05);8696份病案存在1项缺陷,5963份病案存在2项缺陷,632份病案存在3项缺陷,69份病案存在4项缺陷,7份病案存在5项缺陷,2份病案存在6项缺陷,占比依次为56.58%、38.80%、4.11%、0.45%、0.05%和0.01%。结论基于信息技术能够快速高效对住院病案首页质量进行评估,住院病案首页缺陷主要涉及基本信息和诊疗信息两部分内容,但在诊疗信息内涵质量评估方面规则还待进一步挖掘。

Objectives This study aims to use information technology to evaluate the data on the front page of inpatient medical records to provide a reference for improving the quality of data on the front page of inpatient medical records.Methods According to the basic rules for disease and surgical coding,the principles for selecting major diagnoses,and the standards for reporting performance evaluation data in public hospitals,validation rules were set up to automatically generate non-standard medical record front page information and prompt detailed errors,which were checked and made corrections one by one by the quality control physicians,from January 1,2023 to Jane 31,2023.Results Among 51,185 medical records,15,369 medical records had defects,of which the internal medicine defect rate was 28.46%and the surgical defect rate was 31.30%.The difference was statistically significant(χ^(2)=48.36,P<0.05).8696 medical records had 1 defect,5963 medical records had 2 defects,632 medical records had 3 defects,69 medical records had 4 defects,7 medical records had 5 defects,and 2 medical records had 6 defects,accounting for 56.58%,38.80%,4.11%,0.45%,0.05%,and 0.01%,respectively.Conclusions Based on information technology,it is possible to evaluate the quality of the home page of inpatient medical records quickly and efficiently.The defects on the front page of hospitalization medical records mainly involve two parts:basic information and diagnosis and treatment information.However,the rules for assessing the connotation and quality of diagnosis and treatment information need to be further explored.