摘要
目的基于《病案管理质量控制指标(2021年版)》,对湖北省武汉市某三甲医院的住院病历内涵质量进行评估。方法从该院各科室医疗组随机抽取2022年1月1日—2022年8月30日期间的住院病历共762份参与评估,采用科室质控员互查及病案督导专家重点复查的形式完成评估。结果病案首页24小时内完成率较低,为29.66%。重大检查记录符合率均在70%~80%范围内,诊疗行为记录的符合率范围在80%以上,其中抗菌药物使用记录符合率最低,为80.63%。重大检查及诊疗行为记录不符合的主要原因为病程书写不规范。病历归档质量指标中,主要诊断与主要手术的填写正确率均在97%以上,编码正确率达到99%。结论《病案管理质量控制指标(2021年版)》的发布为各级医疗机构的病案管理工作提供了更加科学全面的质量控制体系。未来应加强医疗信息化技术的发展,实现全量病历内涵质量的自动化评估。
Objective To assess the content quality of hospital medical records from a Class A tertiary hospital in Wuhan,Hubei province,based on“Quality Control Index of Medical Record Management(2021 Edition)”.Methods We selected 762 hospital medical records,which were randomly selected from each medical group from January 1,2022 to August 30,2022.The quality was assessed by the way of inspection of quality controller from each department and the review of supervision experts for disputable medical records.Results The completion rate of front page of hospital medical records within 24 hours was as low as 29.66%.The conformity rates of major inspection records were in the range of 70%~80%.The conformity rates of records of diagnosis and treatment behavior were all over 80%,among which the conformity rate of records of antibacterial drug use was the lowest at 80.63%.The primary cause of the non-conformity of major inspection records and records of diagnosis and treatment behavior was the poorly written progress nots.Among indexes about quality of filed medical records,the main diagnosis and main operation could be written with over 97%accuracy,and the accuracy of coding reached 99%.Conclusion The release of“Quality Control Index of Medical Record Management(2021 Edition)”provides a more scientific and comprehensive quality control system for medical record management.Therefore we should strengthen the development of medical informatization and materialize the automatic evaluation of the connotation quality of large amounts of medical records.
作者
王璐琳
裴益
周云
何艺
WANG Lulin;PEI Yi;ZHOU Yun;HE Yi(Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology,Wuhan 430030,China)
出处
《现代医院》
2023年第7期1037-1040,共4页
Modern Hospitals
基金
湖北省卫生健康委员会科研项目(WJ2021M120)。
关键词
住院病历
内涵质量
病案管理质量控制指标
Inpatient medical records
Content quality
Quality control index of medical record management
