摘要
目的通过病案首页质控提高医疗统计信息的准确性,为DRGs付费制度奠定基础,为医院的管理和决策提供信息支持。方法建立医院病案首页质量控制体系,制定《病案首页质量控制评分表》,抽取某院实施病案首页质控前后共10 402份病案进行填报质量评分,采用SPSS19.0对比分析质控前后病案首页信息的完整度、错误率、得分情况。结果建立病案首页质控体系后,病案首页填写不完整率降低,差异有统计学意义(χ2=256.28,P<0.001);入院病情填写、门诊诊断、手术及操作日期、麻醉方式、切口愈合等级、手术级别、出生地址、身份证号、新生儿出生体重等错误率均有所下降,差异有统计学意义(P<0.05);病案首页质控评分差异有统计学意义(Z=-20.322,P<0.001)。结论建立病案首页质量控制体系使病案首页填写质量得到有效提升,同时病案首页的质量控制需要多个部门共同协作,持续为病案首页质量把关。
Objective By controlling the quality of medical record home page, in order to enhance the quality of medical records, to improve the accuracy of medical statistics, to lay the foundation for DRGs payment system, and to provide information support for the hospital＇s management and decision-making. Methods Established hospital medical record quality control system, made ＂quMi（y control ofmedl＂cM record score table＂, extracted a total of 10402 copies of medical records home quality control score before and after control, and using SPSS19.0 to comparative analysis of quality control before and after Home completeness of information, error rate, scores. Results The rate of incomplete medical records reduced after quality control, the difference was statistically significant （X =256. 28, P〈0. 001）. The admission condition fill, fill in out-patient diagnosis, surgery and the operation date, anesthesia, wound healing decline before levels, the level of surgery, birth address, ID number, birth weight and other quality control and the error rate lower than before, those differences was statistically significant （P〈0.05）. The difference of the score was statistically significant （Z=-20. 322, P〈0. 001）. Conclusion The medical record quality control system can improve medical record completed rate and accuracy rate. Medical home quality had effectively improve, it should be continue to implement the medical record quality control. At the same time, the quality control of the medical record needs a number of departments to work together to maintain the quality of the medical records.
出处
《中国病案》
2017年第6期23-26,共4页
Chinese Medical Record
关键词
病案首页
填写
质量控制
体系
Medical record home page
Fill in
Quality control
System
