摘要
目的探讨病案信息化管理技术在病案室编码和病案质量中的应用价值。方法选取2021年1月—2022年12月淄博市妇幼保健院2000例住院病案资料为研究对象。其中2021年1—12月实施常规管理为对照组;2022年1—12月实施病案信息化管理技术为观察组,每组1000例。比较两组病案室编码录入错误情况,比较两组病案首页缺项、书写错误项目及病案首页常见错误情况,比较两组病案调阅耗时、病案归档耗时及病案首页质控评分变化。结果观察组主要诊断编码错误、其他诊断编码错误、损伤和(或)中毒编码错误低于对照组,差异有统计学意义(P均<0.05)。观察组病案首页缺项和书写错误项目比例低于对照组,差异有统计学意义(P均<0.05)。观察组病案首页常见错误中,诊断选择错误、地址邮编填写不全、手术或操作名称遗漏的比例均低于对照组,差异有统计学意义(P均<0.05)。观察组病案调阅耗时、病案归档耗时短于对照组,差异有统计学意义(P均<0.05)。病案首页质控评分高于对照组,差异有统计学意义(P<0.05)。结论通过病案信息技术管理,可有效降低病案室编码录入错误率,提高病案首页填写质量,缩短病案调阅和归档耗时,从而整体提高病案管理效率。
Objective To explore the application value of medical record information management technology in medical record room coding and medical record quality.Methods The data of 2000 inpatients in Zibo Maternal and Child Health Hospital from January 2021 to December 2022 were selected as the study objects.From January to December 2021,routine management was implemented as the control group,and from January to December 2022,medical record information management technology was implemented as the observation group,with 1000 cases in each group.The error of code entry in the medical records room of the two groups was compared,and the missing items,writing errors in the first page of medical records of the two groups were compared,as well as the common errors in the first page of medical records.The time spent in retrieving medical records,the time spent in archiving medical records and the changes in quality control scores on the first page of medical records were compared.Results The main diagnostic coding errors,other diagnostic coding errors,injury and(or)poisoning coding errors in the observation group were lower than those in the control group,the differences were statistically significant(all P<0.05).The proportion of missing items and writing errors on the first page of medical records in the observation group were lower than those in the control group,the differences were statistically significant(both P<0.05).The proportions of wrong diagnosis selection,incomplete address and zip code filling,and missing surgery or operation name filling were all lower than those in the control group,the differences were statistically significant(all P<0.05).The time consuming of medical records retrieval and archiving in the observation group were shorter than those in the control group,the differences were statistically significant(both P<0.05).The quality control score of the first page of medical records was higher than that in the control group,the difference was statistically significant(P<0.05).Conclusion The information te
作者
胡晓娟
边纯梅
张红艳
HU Xiaojuan;BIAN Chunmei;ZHANG Hongyan(Medical Records Department,Zibo Maternal and Child Health Hospital,Zibo,Shandong Province,255000 China;Medical Record Department,Zibo Central Hospital,Zibo,Shandong Province,255000 China)
出处
《中国卫生产业》
2023年第22期17-20,共4页
China Health Industry
关键词
病案
信息化管理
病案室
病案编码
病案质量
Medical records
Information management
Medical record room code medical record
Quality of medical records
