某三甲中医医院住院病案首页逻辑校验对数据质量的影响

The Effect of Logical Verification Rule on the Data Quality of Inpatient Medical Records Front Page in a Tertiary TCM Hospital

目的探讨住院病案首页逻辑校验规则对于提高中医住院病案首页质量的作用,为医保付费、绩效考核评价和医疗质量安全提供决策依据。方法提取使用校验前2022年1月1日-6月30日16399份住院病案首页作为对照组,使用校验后2022年7月1日-2022年12月31日18237份住院病案首页作为实验组,用卡方检验分析两组住院病案首页填写准确率。结果依据住院病案首页填写规范要求制定逻辑校验规则305条,实施逻辑校验规则后缺陷数量由1970下降到1105,准确率由87.99%提升到93.94%,经卡方检验,χ^(2)=377.88,P<0.05,差异大多具有统计学意义。结论建立建全中医住院病案首页逻辑校验规则,针对中医住院病案首页进行相应培训,大大减少了人工漏填、错填的情况,并保证了中医住院病案首页诊疗信息的完整性、准确性和合理性,提高了住院中医住院病案首页填写信息的质量。

Objectives This study aims to discuss the role of logical verification rules on the front page of medical records in improving the quality of the front page of traditional Chinese medicine inpatient medical records,so as to provide a decision-making basis for medical insurance payment,performance evaluation and medical quality safety.Methods 16,399 inpatient medical record front pages from January 1 to June 30,2022 before verification were extracted and used as a control group.The front pages of 18,237 inpatient medical records from July 1,2022 to December 31,2022 were used as the experimental group.Chi-square test was used to analyze the accuracy of filling in the first page of the inpatient medical records of the two groups.Results 305 logical verification rules were formulated based on the standard requirements for filling in the front page of hospitalization medical records.After implementing the logic verification rules,the number of defects dropped from 1970 to 1105,and the accuracy increased from 87.99%to 93.94%.After the chi-square test,χ^(2)=377.88,with a significance level of P<0.05,indicating that most of the differences were statistically significant.Conclusions The implementation of logical verification rules for the front page of all Chinese medicine inpatient medical records,along with corresponding training,has significantly reduced instances of manual omissions and incorrect entries.This has ensured the completeness,accuracy,and rationality of diagnosis and treatment information on these records,ultimately enhancing their quality.