病案首页HQMS上传数据现状及改进措施
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摘要
目的分析某院病案首页HQMS数据上传现状,提高HQMS网络上报数据质量。方法抽取某院2015年1月1日-2017年12月31日3年上传的HMQS病案首页数据,回顾性分析HQMS上传情况及病案首页填写质量。结果 HQMS病案首页上传主要存在上传缺漏、上传错误等问题,其中上传缺漏情况较严重,2015年出院病案共92473份,缺漏率10. 83%,2016年出院C共96 501份,缺漏率9. 29%,2017年共出院103 147份,缺漏率8. 83%,上传数据错误为数据代码错误及逻辑错误,2015年-2017年间上传缺漏情况及上传错误问题均逐年改善。结论 HQMS数据上传系统有待完善,应设定标准的疾病和手术字典库,组织有资质的编码员上岗,加强病案首页填写的规范化管理,提高病案首页质量。
Objectives To analyze the upload status of HQMS data in the front page of a medical record, and improve the quality of HQMS network reporting data. Methods To select the HQMS medical record front pages data in three years from 2015 to 2017 in a hospital. Then reviewed the uploading and filling quality of front pages HQMS.Results There were mainly uploading and missing data and uploading data errors on HQMS front pages uploads. It was serious to upload missing conditions, during 2015 to 2017, upload omissions and upload errors were improving year and year. Conclusions HQMS data upload system still needed improvement, we should set up standard disease and operation dictionary libraries, organize qualified coders to work, strengthen the standardized of front pages filling and improve the quality of the front pages of medical records.
Objectives To analyze the upload status of HQMS data in the front page of a medical record, and improve the quality of HQMS network reporting data. Methods To select the HQMS medical record front pages data in three years from 2015 to 2017 in a hospital. Then reviewed the uploading and filling quality of front pages HQMS.Results There were mainly uploading and missing data and uploading data errors on HQMS front pages uploads. It was serious to upload missing conditions, during 2015 to 2017, upload omissions and upload errors were improving year and year. Conclusions HQMS data upload system still needed improvement, we should set up standard disease and operation dictionary libraries, organize qualified coders to work, strengthen the standardized of front pages filling and improve the quality of the front pages of medical records.
引文
[1]孟楠,贾静,李海明,等.医院质量监测系统在医院管理及临床服务中的应用[J].中国医院管理,2014, 34(5):33-34.
[2]肖晓兰,贺海平,赵杰,等.医院质量监测系统(HQMS)网络直报的思考与建议[C].中国医院协会病案管理专业委员会学术会议,2013:315-317.
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[4]张红,韦秀碧,著铭.病案首页填写中人为因素对HQMS数据的影响[J].中国病案,2014, 15(8):12-14.
[5]范俊叶,冯晓玲,范俊生,等.病案首页HQMS数据直报工作的探讨[J].中国病案,2014,15(5):45-46.
[6]肖晓兰,左传田,贺海平,等.12367份病案首页HQMS网络直报的质量分析[J].中国病案,2014, 15(1):28-30.
[7]卫生部.关于修订住院病案首页的通知[Z].卫医政发(2011)84号,2011.
[2]肖晓兰,贺海平,赵杰,等.医院质量监测系统(HQMS)网络直报的思考与建议[C].中国医院协会病案管理专业委员会学术会议,2013:315-317.
[3]楼婷,韩学美,王颖莹.病案首页主要诊断填写缺陷分析及对策[J].中国病案,2013, 14(3):15-16.
[4]张红,韦秀碧,著铭.病案首页填写中人为因素对HQMS数据的影响[J].中国病案,2014, 15(8):12-14.
[5]范俊叶,冯晓玲,范俊生,等.病案首页HQMS数据直报工作的探讨[J].中国病案,2014,15(5):45-46.
[6]肖晓兰,左传田,贺海平,等.12367份病案首页HQMS网络直报的质量分析[J].中国病案,2014, 15(1):28-30.
[7]卫生部.关于修订住院病案首页的通知[Z].卫医政发(2011)84号,2011.