常州某三级医院电子病案首页智能化质控分析

Intelligent Quality Control Analysis of Electronic Medical Record Front Page of a Third-Level Hospital in Changzhou

目的通过智能化质控提高电子病案首页质量来进一步提升三级公立医院绩效考核评分,使医院得到更精细化的发展。方法运用戴明环(plan-do-check-act,PDCA)的方法进行病案质量控制,选取常州市第四人民医院2022年7—12月的出院病历共15814份作为非PDCA组,2023年7—12月的出院病历共17684份作为PDCA组。比较2组住院病案首页基本信息与逻辑信息两大类质控项目中各项目缺陷率。结果PDCA组基本信息中漏填籍贯标准地址库代码为0,漏填付费方式为0,婚姻填写错误0.03%,漏填身份证号码为0.24%,逻辑性信息中漏填病理诊断附码为0.37%,主要诊断编码为国际疾病分类(international classification of diseases,ICD)编码S或者T开头的编码漏填损伤中毒码为0,疾病诊断编码错误为1.39%,手术操作编码错误为0.61%,漏填手术操作记录为0,漏填血型为0,漏填离院方式为0,死亡患者尸检填写错误为0,低于非PDCA组的100%、0.06%、1.39%、0.66%、5.82%、0.26%、4.07%、2.18%、0.92%、0.47%、0.57%、100%,差异有统计学意义(P<0.001)。结论医院需要通过加大病案首页填报培训、管理部门强化质量监管,加强病案信息实时监控系统,多部门联动,重视住院病案首页质量,提高三级公立医院绩效考核中的评分等级。

Objective To further improve the performance assessment scores of tertiary public hospitals by improving the quality of electronic medical record first pages through intelligent quality control,thus enabling hospitals to achieve more refined development.Methods The plan-do-check-act(PDCA)cycle method was employed for medical record quality control.A total of 15814 discharge records from July to December 2022 of Changzhou Fourth People's Hospital were selected as the nonPDCA group,and 17684 discharge records from July to December 2023 were selected as the PDCA group.The defect rates of each item in two categories of quality control items,basic information and logic information,were compared between the two groups of inpatient medical records.Results In the basic information of PDCA group,omission of code of the standard address library of the home place was 0,omission of payment method was 0,the marriage filling error was 0.03%,omission of ID card number was 0.24%,omission of omission of pathology diagnosis attachment codes was 0.37%in the logical information,and omission of main diagnosis code was international classification of diseases(ICD)code and the code beginning with S or T as injury and poisoning code 0,the error of disease diagnosis code was 1.39%,the error of surgical procedure code was 0.61%,omission of surgical procedure record was 0,the error of blood type was 0,the error of discharge method was 0,and omission of anesthesiologists was 0,which were lower than 100%,0.06%,1.39%,0.66%,5.82%,0.26%,4.07%,2.18%,0.92%,0.47%,0.57%,100%in the nonPDCA group,and the difference was statistically significant(P<0.001).Conclusion Hospitals need to enhance EMR first page filling training,strengthen quality supervision by management departments,improve real-time monitoring systems for medical record information,coordinate multiple departments,prioritize the quality of inpatient electronic medical record first pages,and raise the score levels in the performance assessment of tertiary public hospitals.