摘要
目的基于三级妇幼保健绩效考核的重要性,分析泰安市妇幼保健院住院病案首页缺陷,查找原因,并且提出改进措施。方法按照出院科别不同,按照50%的比例随机抽取2020年8月—2021年12月泰安市妇幼保健院出院病历16000份进行首页质控,列出缺陷数据明细,进行统计分析。结果16000份病案首页出现问题病案1722份,缺陷总频数为1926次,其中住院基本信息缺陷674次,占34.99%;过程信息缺陷191份,占9.92%;诊疗信息缺陷982次,占50.99%;费用信息缺陷79次,占4.10%。问题病案科别中手术科室(包括儿外科、五官科、妇科、产科、生殖健康科、成人外科)共1338份,占77.70%;非手术科室(儿内科、成人内科)384份,占22.30%,手术科室是出现问题病案的主要科室。结论医院住院病案首页质量有待提高,医院应加强多科室协作,住院信息登记处、临床科室、病案科、医务科、财务科、信息科相互配合,奖惩分明,共同努力,加强质量管理,特别是加强手术科室的质量管理,保证病案首页质量稳步提升。
Objective Based on the importance of three-level maternal and child health performance evaluation,ana⁃lyze the defects on the homepage of inpatient medical records in Tai'an Maternal and Child Health Hospital,identify the reasons,and propose improvement measures.Methods According to different discharge departments,16000 dis⁃charged medical records from Taian Maternal and Child Health Hospital from August 2020 to December 2021 were randomly selected in a 50%proportion for homepage quality control,and defect data details were listed for statistical analysis.Results There were 1722 problematic cases on the first page of 16000 cases,and the total frequency of de⁃fects was 1926,including 674 defects in basic hospitalization information,accounting for 34.99%;191 defects in pro⁃cess information,accounting for 9.92%;982 defects in treatment information,accounting for 50.99%;79 defects in cost information,accounting for 4.10%.Among the problematic case departments,there were 1338 surgical depart⁃ments(including pediatric surgery,otolaryngology,gynecology,obstetrics,reproductive health,and adult surgery),ac⁃counting for 77.70%,and 384 non-surgical departments(pediatric internal medicine and adult internal medicine),ac⁃counting for 22.30%,with surgical departments being the main departments with problematic cases.Conclusion The quality of hospital inpatient case home page needs to be improved,the hospital should strengthen multi-departmental collaboration,inpatient information registry,clinical departments,case department,medical department,financial de⁃partment,information department,cooperate with each other,rewards and punishments are clear,joint efforts to strengthen quality management,especially strengthen the quality management of surgical departments,to ensure that the quality of cases home page is steadily improved.
作者
杨绪娜
YANG Xu'na(Department of Quality Control,Taian Maternal and Child Health Hospital,Tai'an,Shandong Province,271000 China)
出处
《中国卫生产业》
2023年第8期56-59,共4页
China Health Industry
关键词
妇幼绩效考核
住院病案首页
缺陷
统计分析
疾病编码
Maternal and child performance assessment
Inpatient case home
Defects
Statistical analysis
Disease coding
