16231份住院病案首页缺陷分析及持续改进

Analysis and Continuous Improvement of Defects on the Front Page of 16,231 Inpatient Medical Records

目的通过对住院病案首页质控,分析缺陷原因,持续改进以提升住院病案首页填报质量。方法由2名专职编码员对某院2022年1月1日-2022年12月31日住院病案首页进行质控。其中2022年1月1日-2022年1月31日缺陷项目摸底阶段共1496份,为第1组;2022年2月1日-2022年6月30日精准反馈阶段共6786份,为第2组;2022年7月1日-2022年12月31日加强考核阶段共7949份,为第3组。结果16231份住院病案首页中,3439份病案存在5987项缺陷内容。其中诊疗信息缺陷占比61.02%;其中手术操作漏填33.59%。手术操作漏填2011例次,其中中医康复相关漏填占19.79%;呼吸机使用相关漏填10.45%。缺陷率1组为30.95%、2组25.95%、3组15.28%,组间比较有统计学差异,P<0.01。结论加强住院病案首页质控,可有效降低其缺陷率。医院应建立长效机制,加强病案信息化管理,精准反馈考核,持续改进住院病案首页质量。

Objectives This study aims to conduct quality control on the front page of inpatient medical records,analyze the causes of defects,provide accurate feedback,and continuously improve the quality of filling out the front page of inpatient medical records.Methods Two full-time coders conducted quality control on the front pages of a hospital's inpatient medical records from January 1,2022 to December 31,2022.Among them,there were 1,496 reports in total during the defective project survey phase from January 1,2022 to January 31,2022,which is the first group;there were 6,786 reports in total during the precise feedback phase from February 1,2022 to June 30,2022,which is the second group;there were 7,949 reports in total during the enhanced assessment phase from July 1,2022 to December 31,2022,which is the third group.Results Among the front pages of 16,231 inpatient medical records,3,439 records had 5,987 defective contents.Among them,defects in diagnosis and treatment information accounted for 61.02%,and 33.59%of surgical operations were missed.There were 2011 cases of surgical operation omissions,of which 19.79%were related to traditional Chinese medicine rehabilitation and 10.45%were related to ventilator use.The defect rates were 30.95%in group 1,25.95%in group 2,and 15.28%in group 3.There were statistically significant differences among the groups(P<0.01).Conclusions Strengthening the quality control of the first page of inpatient medical records can effectively reduce its defect rate.Hospitals should strengthen information management,establish long-term mechanisms,provide accurate feedback and assessment,strengthen talent training,and continuously improve the quality of the first page of inpatient medical records.