广东省某医院2020-2022住院病案首页填写质量分析及对策

Quality Analysis and Countermeasures of Filling out the Front Page of Inpatient Medical Records in a Hospital in Guangdong Province from 2020 to 2022

目的通过分析广东省某医院近3年住院病案首页填报数据,针对住院病案首页诊断及手术操作填报缺陷原因,提出持续改进措施,以期提高住院病案首页填报正确率。方法根据住院病案首页数据填写质量规范(暂行)、住院病案首页数据质量评分标准(2016版)填写规范,对广东省某医院2020年1月1日-2022年12月31日期间出院的55705份住院病案首页进行质量监控,分析住院病案首页填写问题。采用描述性统计方法对数据进行分析。结果2492份住院病案首页填写存在缺陷,总体住院病案首页缺陷率为4.47%。填写缺陷2626例次,按照不同类型归类为26项,全部为患者基本信息、住院过程信息、诊疗信息类缺陷问题。占比较高的前4类问题为主要诊断信息缺陷(占比40.63%)、主要手术或操作信息缺陷(占比17.44%)、其他手术或操作缺陷(占比14.28%)、其他诊断信息缺陷(占比14.17%)。结论住院病案首页主要诊断填写选择不准确情况、其他诊断漏填情况较为突出、手术或操作漏填情况占比较大。应强化对临床医师和编码员的ICD编码及住院病案首页填写规则相关知识培训,搭建住院病案首页质控信息系统,推进住院病案首页信息化建设,充分利用住院病案首页智能审核系统等持续改进措施,提高住院病案首页填写的正确率。

Objectives By analyzing the data reported on the front page of inpatient medical records in a hospital in Guangdong Province in the past three years,this study aims to identify the causes of defects in front page diagnosis and surgical procedures and propose continuous improvement measures,so as to improve the accuracy of filling out the front page of the inpatient medical record.Methods According to the Quality Specification for Filling in Data on the Front Page of Inpatient Medical Records(Provisional)and Quality Scoring Standard for Data on the Front Page of Inpatient Medical Records(2016 Edition),the quality of 55705 inpatient medical records from a hospital in Guangdong Province between January 1,2020 and December 31,2022 was monitored and the problems in filling out the front page of inpatient medical records were analyzed.Results Total of 2492 inpatient medical records were filled with defects on the front page,with an overall defect rate of 4.47%.There were 2626 filling defects classified into 26 items according to different types,all of which were related to defects in patient basic information,hospitalization process information,and diagnosis and treatment information.The top four types of problems with a high proportion were defects in main diagnostic information(40.63%),defects in main surgical or operational information(17.44%),defects in other surgical or operational information(14.28%),and defects in other diagnostic information(14.17%).Conclusions The main problems on the front page of the inpatient medical record are the inaccurate selection of main diagnosis on the front page of inpatient medical records,omission of other diagnoses,and omission of surgical or operational information.It is recommended to strengthen training on ICD coding and front-page filling rules for clinicians and coders,promote information construction at hospital level,make full use of continuous improvement measures such as the intelligent review system on the front page and so on,and improve the accuracy of filling in the front page of medical records.The above methods can effectively improve the accuracy of filling in the front page of medical records.