摘要
目的根据三级公立医院绩效考核制定标准,评价住院病案首页的数据现状,分析原因,提出改进措施。方法从某省卫生健康管理服务评价中心提取2019年所有三级公立医院病案首页数据,从编码错误和非编码错误两方面进行统计分析。结果抽取某省80家三级公立医院2019年病案首页2246799份,全省病案首页质控编码错误病案数为395139,占总病案的17.59%,全省病案首页质控非编码错误病案数为881590,占总病案的39.24%。结论病案首页的数据质量对于反映医院综合水平起着举足轻重的作用,应加强数据质控,确保上报数据标准化、规范化,确保数据客观和真实。
Objective To evaluate the data status of the front page of inpatient medical records,analyze the reasons,and put forward improvement measures,according to the performance evaluation standard of tertiary public hospitals.Methods The front page data of medical records of all tertiary public hospitals in 2019 were extracted from provincial health management service evaluation center,and statistical analysis was conducted from coding errors and non coding errors.Results Totally 2246799 medical records of 80 tertiary public hospitals in our province in 2019 were selected.The number of medical records with wrong quality control code was 395139,accounting for 17.59%of the total medical records,and the number of non coding wrong medical records in the front pages of medical records was 881590,accounting for 39.24%of the total medical records.Conclusion The data quality of the front page of the medical records plays an important role in reflecting the comprehensive level of the hospital.We should strengthen the data quality control,ensure the standardization and normalization of the reported data,and ensure the objectivity and authenticity of the data.
作者
王丹
Wang Dan(Qiqihar Hospital of Traditional Chinese Medicine, Qiqihar 161000, China)
出处
《中国医院统计》
2021年第2期165-167,共3页
Chinese Journal of Hospital Statistics
关键词
三级公立医院
病案首页
编码
tertiary public hospital
front page of medical record
code
