住院病案首页质量控制缺陷分析
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摘要
目的分析病案首页质量填写缺陷,探讨病案首页质量填写存在的主要问题。方法《住院病案首页数据填写质量规范(暂行)》和《住院病案首页数据质量管理与控制指标(2016版)》发布后,按照该标准加强病案首页质量监控[1]。抽取2018年某二级医院出院病案1200份,对2018年某二级医院出院病案1200份病案按照标准对病案首页诊断进行质控评价,分析病案首页填写情况及错误原因构成。结果出院诊断、手术和操作以及入院病情的错误填写占了所有缺陷的48%。结论建立健全医院规章制度,完善病案管理系统,加强病案首页质量监督,从而提高病案首页诊断填写的正确率,建议加强临床医师和编码人员培训,建立考核机制,改变绩效考核方法。
Objective Analyze the defect of filling in the front page of the medical record, and probes into the main problems existing in filling in the front page of medical record. Methods After the publish of Standard for filling out the first page data of hospital medical record(interim) and Index of data quality Management and Control on Home Page of Medical record(2016 Edition),quality Control of Home Page of Medical record was strengthened according to this standard.In 2018, 1,200 samples of discharge from a secondary hospital were collected.Quality control evaluation of the front page diagnosis of 1200 samples discharged from a secondary hospital in 2018 according to standard.Analyze the situation of filling in the front page of the sample and the composition of the error.Results 48% of all defects were misfilled in the diagnosis, operation and condition of discharged patients. Conclusion Establishing and perfecting hospital rules and regulations, improving medical record management system and strengthening the quality supervision of the front page of medical records can improve the correct rate of filling in the diagnosis of the front page of medical records. It is suggested that the training of clinicians and coders should be strengthened, the assessment mechanism should be established and the method of performance evaluation should be changed.
Objective Analyze the defect of filling in the front page of the medical record, and probes into the main problems existing in filling in the front page of medical record. Methods After the publish of Standard for filling out the first page data of hospital medical record(interim) and Index of data quality Management and Control on Home Page of Medical record(2016 Edition),quality Control of Home Page of Medical record was strengthened according to this standard.In 2018, 1,200 samples of discharge from a secondary hospital were collected.Quality control evaluation of the front page diagnosis of 1200 samples discharged from a secondary hospital in 2018 according to standard.Analyze the situation of filling in the front page of the sample and the composition of the error.Results 48% of all defects were misfilled in the diagnosis, operation and condition of discharged patients. Conclusion Establishing and perfecting hospital rules and regulations, improving medical record management system and strengthening the quality supervision of the front page of medical records can improve the correct rate of filling in the diagnosis of the front page of medical records. It is suggested that the training of clinicians and coders should be strengthened, the assessment mechanism should be established and the method of performance evaluation should be changed.
引文
[1]李磊磊.基于PDCA法提升住院病案首页信息质量的对策研究[D].内蒙古大学,2017.
[2]薛缪群,孙蓉蓉.住院病案首页填写质量改进效果分析[J].中国病案,2018,19(04):12-14.
[3]刘爱民,主编.病案信息学[M].北京:人民卫生出版社,2014,190.
[4]徐少博.600份病案首页填写缺陷分析及对策[J].中国病案,2018,19(02),31-33.
[2]薛缪群,孙蓉蓉.住院病案首页填写质量改进效果分析[J].中国病案,2018,19(04):12-14.
[3]刘爱民,主编.病案信息学[M].北京:人民卫生出版社,2014,190.
[4]徐少博.600份病案首页填写缺陷分析及对策[J].中国病案,2018,19(02),31-33.