摘要
目的通过应用电子病案管理系统进行住院病案首页医院感染诊断质控,提高住院病案首页和医院感染病例监测系统中的医院感染诊断一致性。方法分析2018年1月1日-2022年12月31日出院患者中经电子病案管理系统召回的医院感染诊断相关病例859例,将召回医院感染诊断相关病例信息建立数据库,应用R 4.2.2统计软件,计数资料采用卡方检验,分析召回比例变化、召回原因构成变化、召回修改后归档时间变化情况。结果2018年医院感染管理处病案召回比例从2018年的0.36%降至2022年0.24%。其中,医院感染漏报所占比例连年下降,已从2018年29.05%下降至2022年的15.25%,2018年召回病案24小时归档率为72.86%,至2019年上升至88.34%,后又有所下降,2022年为74.58%。48小时归档率由2018年的87.62%上升至2019年的95.71%后又有下降,至2022年降至80.79%。结论通过应用电子病案管理系统进行住院病案首页医院感染诊断质控,提升了住院病案首页医院感染诊断质量,提升了病案质控效率。
Objectives Through the application of electronic medical records management system,the quality control of hospital infection diagnosis on the front page of hospital medical records was carried out to improve the consistency of hospital infection diagnosis between the front page of hospital medical records and hospital infection case monitoring system.Methods A total of 859 cases related to nosocomial infection diagnosis recalled by the electronic medical record management system among patients discharged from January 1st,2018 to December 31st,2022 were analyzed.The information of the recalled nosocomial infection diagnosis related cases was established in a database.The statistical software R 4.2.2 was applied,and the counting data was Chi-square test.Analyze the change of recall proportion,the change of recall causes,and the change of filing time after recall modification.Results The proportion of hospital infection management office cases recalled in 2018 decreased from 0.36%in 2018 to 0.24%in 2022.Among them,the proportion of missed reporting of hospital infections had declined year after year,from 29.05%in 2018 to 15.25%in 2022,and the 24-hour filing rate of recalled medical cases in 2018 was 72.86%,rising to 88.34%in 2019,and then decreased,to 74.58%in 2022.The 48-hour filing rate increased from 87.62%in 2018 to 95.71%in 2019 and then declined again to 80.79%in 2022.Conclusions Through the application of electronic medical record management system,the quality of hospital infection diagnosis on the first page of hospital medical records was improved,and the quality control efficiency of hospital medical records was improved.
作者
马文晖
王力红
赵霞
韩叙
王薇
赵会杰
王允琮
Ma Wenhui;Wang Lihong;Zhao Xia;Han Xu;Wang Wei;Zhao Huijie;Wang Yuncong(Department of Nosocomial Infection Management,Xuanwu Hospital,Capital Medical University,Beijing 100053,China)
出处
《中国病案》
2024年第4期21-22,34,共3页
Chinese Medical Record
关键词
医院感染
诊断
住院病案首页
质量管理
Hospital infection
Diagnosis
Front page of inpatient medical records
Quality management
