统计工作对病案首页质控作用的调查分析  

An Analyzed Survey on the Role of Statistical Quality Control to the Front sheet of the Medical Record

作　　者：陈祝萍[1] 

机构地区：[1]广东医学院附属医院信息技术部

出　　处：《中国病案》2008年第6期25-27,共3页Chinese Medical Record

摘　　要：目的通过对病案首页书写质量和录入质量进行监控,以确保统计数据的准确性。方法统计人员认真核查原始病案首页与录入后信息以及每月审核各类统计报表,筛查疑点问题,及时反馈纠正。与此同时调查分析一年来病案首页书写、编码及录入存在问题。结果调查录入病案首页48,853份,发现缺陷病案首页3,652份,占7.48%,其中多项缺陷的病案首页1,037份。总错漏有6956项。结论统计工作的严谨也是对病案首页质量起着重要的环节监控作用。Objective We supervise the coding and quality of the input of the front sheet of the medical record by strengthening the statistics, to guarantee the quality of the documentation of the front sheet of the medical record and ensure the statistics＇ accuracy. Method From January to December in 2007, we examined the input of the front sheet of the medical records everyday, and carefully checked the original medical records and their input and all kinds of statistics forms per month, finding mistakes in time to get the correction and feedback. Result We analyzed the input of the front sheet of 48,853 medical records and found 3652 inaccurate front sheet （7.48 %）. In these front sheet, there were 6956 error items, and 1037 front sheet had multiple faults. The correction to the fault front sheet of the medical records improves the quality of the coding and the input the front sheet. As a result, the statistics＇ accuracy has been ensured. Conclusion Statistics and the front sheet of the medical records supplement each other. Improving the preciseness of statistics plays an important role on inspecting the quality of the front sheet of the medical records.

关 键 词：病案首页 统计工作 质控 分析 

分 类 号：R197.3[医药卫生—卫生事业管理]