基于公立医院绩效考核下的住院病案首页质控分析

Quality Control Analysis of the Front Page of Inpatient Medical Records Based on the Performance Appraisal of Public Hospitals

目的通过对住院病案首页质控的数据进行分析和改进,提升住院病案首页填报质量,保证住院病案首页数据统计的准确性。方法对2022年1月1日-2022年3月31日出院的12971份住院病案首页进行回顾性质控,通过PDCA质控循环管理后,再对2023年1月1日-2023年3月31日12529份病案进行质控,追踪质控效果。将收集到的两组数据用SPSS 27.0统计分析软件进行处理与分析,对两组的各项缺陷率进行比较,采用χ^(2)检验分析,以P<0.05表示差异有统计学意义。结果通过质控并提出措施进行改进,住院病案首页的总体缺陷率由24.45%下降到10.51%,P<0.001。患者信息由10.43%下降到4.53%,其中地址不详由3.95%降到2.08%,职业不符由3.56%降到1.72%,出生地、籍贯错误由3.36%降到1.10%;与诊断相关内容由5.48%下降到3.20%,其中主要诊断选择错误缺陷率由2.51%下降到1.72%,病理信息遗漏由0.86%下降到0.31%,出院转归错误由0.73%下降到0.22%;手术操作相关内容由3.25%下降到0.93%,其中手术级别错误由1.26%下降到0.44%,主要手术操作错误由1.06%下降到0.28%,手术顺序错误由0.97%下降到0.22%,其他手术操作错误由0.48%下降到0.20%;其他相关内容由5.72%下降到2.76%,其中签名不完整由4.42%下降到2.69%,单病种管理缺陷率由1.60%下降到0.44%,临床路径管理错误由0.60%下降到0.22%。结论改进质控体系后住院病案首页填报质量得到提升,但是仍需要完善质控措施,特别是需要建立各部门人员之间的协作。

Objectives Through analyzing and improving the quality control data of the first page of inpatient medical records,the quality of the front page of inpatient medical records was improved and the statistical accuracy of the front page of inpatient medical records was guaranteed.Methods Retrospective quality control was performed on the front page of 12,971 medical records discharged from January 1st,2022 to March 31st,2022.After PDCA quality control cycle management,12,971 medical records from January 1st,2023 to March 31st,2023 were conducted to track the quality control effect.The collected data of the two groups were processed and analyzed with SPSS statistical analysis software,and the defect rates of the two groups were compared withχ^(2) test analysis,and P<0.05 was used to indicate statistically significant differences.Results Through quality control and improvement measures,the overall defect rate of the front page of inpatient medical records decreased from 24.45%to 10.51%,P<0.001.The patient information decreased from 10.43%to 4.53%,the address unknown decreased from 3.95%to 2.08%,the occupation inconsistency decreased from 3.56%to 1.72%,the birthplace and native place error decreased from 3.36%to 1.10%.The content related to diagnosis decreased from 5.48%to 3.20%,the defect rate of major diagnosis selection error decreased from 2.51%to 1.72%,pathological information omission decreased from 0.86%to 0.31%,and discharge outcome error decreased from 0.73%to 0.22%.The content related to surgical procedures decreased from 3.25%to 0.93%,among which surgical grade errors decreased from 1.26%to 0.44%,major surgical procedure errors decreased from 1.06%to 0.28%,surgical sequence errors decreased from 0.97%to 0.22%,and other surgical procedure errors decreased from 0.48%to 0.20%.Other related content decreased from 5.72%to 2.76%,among which incomplete signature decreased from 4.42%to 2.69%,single disease management defect rate decreased from 1.60%to 0.44%,clinical path management error decreased from 0.60%to 0.22%.Conclusions After the improvement of the quality control system,the quality of the front page of hospital medical records was improved,but it was still necessary to improve the quality control measures,especially to establish the cooperation between the staff of various departments.