摘要
目的 开展全流程的病案首页数据质控,提高病案首页数据质量。方法 开展全流程调研分析现状,使用鱼骨图、二八法则等质量管理工具找出住院病案首页主要问题,从规则、流程、平台和人员等角度开展提高住院病案首页数据质量实践。结果 对实施干预措施前后的病案首页数据完整性、一致性、规范性和逻辑性进行卡方检验分析。结果显示,干预措施实施后病案首页各类缺陷均显著减少(P<0.05),整体住院病案首页数据质量提升。结论 利用系统整改流程完善系统功能,建立住院病案首页质控规则库,依托大数据平台开展全流程质控和治理,能够有效提高住院病案首页数据质量,具有一定的创新性和行业参考价值。
Objective Realizing high-quality medical records via whole-process quality control of medical record home page.Methods Carrying out analysis of the whole-process research status,utilizing quality management tools such as thefishbone diagram or the 80-20 rule tofind out the main problems of medical record home page,and the practice to improve medical record home page was carried out from the perspective of rule,process,platform and personnel.Results The completeness,consistency,normativity and logic of medical record home page before and after the implementation of the measures were analyzed by chi-square test,the results suggest that there were significant differences between the two phases(P<0.05),indicating that the overall quality of medical record home page was significantly improved.Conclusion Utilizing the system rectification process to improve system functions,establishing the quality control rule base of the front sheet of in-patient medical records.Relying on the big data platform to carry out whole-process quality control and management,thus effectively improved the quality of medical record home page,which has certain innovation and industry reference value.
作者
马傲
马晴
葛小玲
MA Ao;MA Qing;GE Xiaoling(Children’s Hospital of Fudan University,Shanghai 201102,China)
出处
《中国卫生信息管理杂志》
2025年第1期82-88,共7页
Chinese Journal of Health Informatics and Management
关键词
住院病案首页
数据质量
医疗大数据平台
病案管理
medical record home page
data quality
medical big data platform
management of medical record
