摘要
目的:通过信息化和管理手段,实现病案首页数据的全流程管理,提高首页数据质量。方法:通过分析2017年1月1日至6月30日的59 691份病案首页信息,找出首页主要缺陷及原因,通过系统改造,建立一套从医生端到病案室的首页质控流程,配合相关管理政策,形成一套完整的首页质控体系。结果:首页数据质量整体提高21.00%,圆满完成国家病案首页数据上报,2019年数据审核通过率达到99.9%。结论:该质控体系有效提高了首页数据的完整性、一致性和正确性,为医院的绩效考核管理和DRGs付费提供良好的数据基础。
Objective:To realize the entire process management of the home page data of medical records and improve the quality of the first page data by means of informationization and management.Methods:By analyzing 59,691 home page of medical records from January 1st,2017 to June 30th,2017,the main defects and causes of the home were found,and through the corresponding system transformation,a set of quality control closed-loop processes from the doctor to the medical record room were established,in cooperation with related management policies,form a closed-loop quality control system.Results:The overall homepage data quality has increased by 21.00%,and the national performance homepage data report has been successfully completed.In 2019,the data review pass rate reached 99.9%.Conclusion:This quality control system effectively improves the integrity,consistency and correctness of the homepage data,and provides a good data foundation for the hospital's performance assessment management and DRGs payment.
作者
任晓霞
李进燕
谭慭薪
王娟
王靖
REN Xiao-xia;LI Jin-yan;TAN Yin-xin(Department of Information Centre,the First Affiliated Hospital of Chongqing Medical University,Chongqing 400010,P.R.C)
出处
《中国数字医学》
2021年第3期88-91,共4页
China Digital Medicine
关键词
首页质控
数据质量
流程控制
闭环管理
quality control of home page of medical records
data quality
process control
closed-loop management
