某省三甲医院住院病案首页填报质量的影响因素及对策

Factors Influencing the Quality of In-Patient Medical Records Filling in the First Page of Grade A Tertiary Hospital in a Province and Countermeasures

目的研究三甲医院住院病案首页填报质量的影响因素及对策。方法选取某省三甲医院2022年2月—2023年10月共3976份住院病案作为研究对象,同时根据3976份住院病案调查对应249名住院医师具体个人信息,并以此进行影响因素分析。结果参与本研究住院医师中男性群体占比较高,达到61.85%;医师主要来源于临床职工,达到54.62%;医师学历中硕士占比较高,达到53.41%;工作时间也多数在1年以上。在进行住院医师住院病历首页填写培训中,整体还有较大改善空间,同时住院医师自主学习主动性也有待提升。住院医师对病案首页信息填写质量认知水平整体较低,有待提升。多因素logistic回归分析结果显示,住院医师工作时间、住院医师规范化操作培训、病案首页信息填写培训、首页抽查质控均为影响住院病案首页信息填写质量的主要因素(P<0.05)。结论住院医师工作时间、住院医师规范化操作培训、病案首页信息填写培训、首页抽查质控均为影响住院病案首页信息填写质量的主要因素,通过及时根据影响因素采取相应改善措施,可高效促使住院病案首页填写信息的质量显著改善,促进后续病案信息管理质量不断提升。

Objective To study the influencing factors and countermeasures of the quality of in-patient medical records filling on the first page of grade A tertiary hospital.Methods A total of 3976 inpatient medical records from February 2022 to October 2023 in a provincial grade A tertiary hospital were selected as the object of this study,and at the same time,according to 3976 inpatient medical records,the specific personal information of 249 resident doctors was investigated,and the influencing factors were analyzed.Results In this study,male resident doctor accounted for a relatively high proportion of 61.85%.Doctors mainly came from clinical staff,accounting for 54.62%.The master's degree accounted for 53.41%of doctors'education.Most of the working time is more than 1 year.In the training of residents in filling out the first page of medical records,there was still a lot of room for improvement as a whole,and residents'autonomous learning initiative also needs to be improved.The overall cognition level of residents on the quality of information filling in the first page of medical records was low,which needs to be improved.The results of multivariate logistic regression analysis showed that the working hours of residents,the standardized operation training of residents,the training of information filling on the front page of medical records,and the quality control of random check on the front page of medical records were the main factors affecting the quality of information filling on the front page of medical records(P<0.05).Conclusion Working hours of residents,standardized operation training of residents,information filling training on the front page of medical records,and random check quality control on the front page of medical records are the main factors affecting the quality of information filling on the front page of medical records.By taking corresponding improvement measures according to the influencing factors in time,the quality of information filling on the front page of medical records can be effectively improved significantly.Promote the continuous improvement of the quality of follow-up medical record information management.