摘要
目的分析加强病案首页质量监控前后诊断填写质量的变化,探讨病案首页质量控制对病案首页诊断填报质量的影响。方法《住院病案首页数据填写质量规范(暂行)》和《住院病案首页数据质量管理与控制指标(2016版)》发布后,按照该标准加强病案首页质量监控。分别抽取2015年5月-2016年4月质控前的6236份,加强质量监控后2016年7月-2017年6月的6936份病案按照标准对病案首页诊断进行质控评价,分析两组病案首页诊断填报、主要诊断、其他诊断填报情况及错误原因构成。结果加强质控后组,病案首页诊断填报准确性、主要诊断填报质量、其他诊断填报质量均好于质控开展前,P<0.01。质控工作开展前错误原因主要为漏填诊断、填写错误、编码选择错误分别占全部错误的30.09%、21.63%、20.69%;质控工作开展后错误原因主要为多填诊断、编码选择错误,分别占30.98%、23.37%。结论加强病案首页质控提高临床医师诊断书写和编码员编码的水平,从而提高病案首页诊断填写的正确率,建议加强临床医师和编码人员培训,建立考核机制,改变绩效考核方法。
Objective This paper analyzes the changes of the quality of diagnosis and filling before and after strengthening the quality control of the front page of the medical record,and probes into the influence of the quality control of the front page of the medical record on the quality of the diagnosis and report of the front page.Methods After the publish of Standard for filling out the first page data of hospital medical record(interim) and Index of data quality Management and Control on Home Page of Medical record(2016 Edition),quality Control of Home Page ofMedical record was strengthened according to this standard.6236 samples were collected from May 2015 to April 2016 before quality control,6936 medical records from July 2016 to June 2017 were collected after strengthening quality control.According to the standard,the quality control evaluation was carried out on the first page of medical record,and the diagnosis and report of the front page,main diagnosis,other diagnoses fill out the situation and the wrong reason constitute of two groups of medical records were analyzed.Results After the quality control was strengthened,the diagnostic and report accuracy of the first page of the medical record was improved,and the quality of the other diagnoses was better than that before the development of the quality control(P<0.01).Before the quality control work was carried out,the main causes of errors were leakage diagnosis,filling errors and coding selection errors,which accounted for 30.09%,21.63% and 20.69% of the total errors respectively.After the quality control work was carried out,the main causes of errors were multi-filling diagnosis and coding error,which accounted for 30.98%,23.37% respectively.Conclusion Strengthening the quality control of the first page of the medical record to improve the level of the clinician’s diagnosis and the coding staff’s coding,thus improving the correct rate of the diagnosis and filling in the first page of the medical record.It is suggested to strengthen the training of the cl
作者
刘凤银
Liu Fengyin(Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China)
出处
《中国病案》
2018年第12期26-29,共4页
Chinese Medical Record
关键词
病案首页
质量控制
诊断填报
影响
First page of medical record
Quality control
Diagnosis and report
Influence
