摘要
目的应用病案首页质量控制系统,加强病案首页填写环节质量的控制,提高病案首页填写终末质量。方法通过病案首页质量控制系统,提取2011年1月至2015年12月每年病案首页环节质量控制发送"病案首页填写错误"、"首页填写超期"及"首页错误修改超期"三大类反馈信息条数,各年三大类反馈信息条数与出院人次的占比,观察2011年至2015年三大类反馈信息的变化情况;同时,随机抽取2011年至2015年全院2 080份出院病历(26个临床科室,每季度20份),按照《病案首页填写规范》的诊断信息、手术信息、其它信息三大类项目,逐项检查出院纸质病案首页填写质量情况,分析病案首页质量控制系统应用后与出院纸质病案首页填写的关联性。结果 2011至2015年病案首页填写错误信息占比逐年下降从2011年的36.69%,下降至2015年24.22%,出院纸质病案首页填写终末质量合格率呈逐年上升的趋势,从2011年81.63%,上升到2015年95.38%。病案首页质量控制系统对病案首页填写的环节质量控制,与病案首页填写终末质量(出院纸质病案首页)提高有直接的相关性;结论通过病案首页质量控制系统的应用,保证了病案首页填写的规范性,提高了出院纸质病案首页填写质量,解决了医疗数据统计的及时性与准确性。为医疗、科研、教学、临床路径、疾病诊断相关分组(DRGS)等医疗数据的挖掘与利用,提供完整、准确、及时的医疗信息资源平台。
Objective To evaluate the ultimate quality of medical record homepage using medical record homepage quality monitoring system in the writing process of medical record homepage. Methods The data of transmission on the information including ＂mistakes on medical record homepage＂, ＂out of date in filling in medical record homepage ＂ and ＂out of date in correcting the mistakes ＂ and their proportions in patients who discharged in hospital from January, 2011 to December, 2015 were extracted to observe the alteration of the above-mentioned three kinds of information. A total of 2 080 medical records （20 medical records each quarter from every department） were randomly selected annually to evaluate the quality of printed medical record homepage and to analysis the effect of medical record homepage quality monitoring system on the quality of printed medical record homepage, according to the ＂specification on fill in medical record homepage＂ including the diagnosis information, operation information and other information. Results The qualified primed medical record homepage proportion was significantly increased from 81.63% （2011） to 95.38%（2015） along with the decrease of the rate of mistakes on medical record homepage （ from 36.69% to 24.22% ）. It was conducted that the application of medical record homepage quality monitoring system was effective in improving ultimate quality of printed medical record homepage. Conclusions The application of medical record homepage quality monitoring system guarantes the standardization of filling in medical record homepage, evaluates the quality of quality of printed medical record homepage and achieves the timeliness and accuracy of medical data, which will provide integral, opportune and effective medical information resources platform to excavate andutilize the medical data in medicine, education, research, clinical pathway and diagnosis related group system （DRGS）.
出处
《中华肺部疾病杂志（电子版）》
CAS
2016年第5期533-536,共4页
Chinese Journal of Lung Diseases(Electronic Edition)
基金
国家自然科学基金资助项目(81201498)
重庆市科技攻关基金资助项目(cstc2015shms-ztzx10001)
关键词
质量
病案首页
信息反馈
效果分析
Medical record homepage
Medical record homepage quality monitoring system
Effectanalysis
