病案首页信息质量对单病种管理的影响  

Effect of the Information about the Front Sheet of Medical Record on the Quality of Single Disease Management

作　　者：潘昀[1] 都鹏飞[1] 胡胜英[1] 胡峻[1] 汪树枝[1] 肖利敏[1] 蒋雯雯[1] 耿敏[1] 

机构地区：[1]安徽医科大学第二附属医院医疗保障部,合肥市230601

出　　处：《中国病案》2014年第6期30-33,共4页Chinese Medical Record

摘　　要：目的通过统计某三甲医院三年病案首页信息数据,分析医院主要住院病种的部分质量控制指标,为医疗质量管理提供依据。方法统计2009年-2011年所有出院病人病案首页的部分信息,选择该医院具有代表性的十个病种,对围手术期死亡率等主要质量控制指标进行分析,并与全国300家同级综合医院的数据进行比对。结果围手术期住院死亡率2009年-2011年均高于统计医院基准值0.10%;住院患者压疮发生率2010年和2011年均高于统计医院基准值0.05%;主要病种的病死率符合要求;大部分病种的再入院率高于平均水平。结论部分病种控制指标仍有差距,需要提高病案首页信息的质量,强化信息反馈工作,保证单病种的规范管理。Objective By collecting the 3-year information about the front sheet of medical record of a third-grade class-A hospital, to analyze the part quality control index of the major hospitalized disease within the hospital, to provide a basis for the medical quality management. Methods Summarizing all the discharged patients＇ the partial information about the front sheet of medical record from 2009 to 2011, the primary quality control index of the representative and selected 10 diseases was analyzed objectively, and compared with the same level general 300 hospitals accurately, to reflect the last 3-year medical quality management circumstance of the hospital clearly. Results Peri operation period mortality from 2009 to 2011 were higher than the reference value of 0.10%; pressure ulcer incidence in 2010 and 2011 were higher than the reference value of 0.05%; the demand of the case fatality rate of the main diseases was met, and the rehospitalization rate of the major diseases was higher than the average simultaneously. Conclusions Some disease control indicators still have difference. We need to further improve the quality of the front sheet of medical record information, strengthen the information feedback, guarantee the management standard of single disease.

关 键 词：病案首页 单病种质量 管理 

分 类 号：R197.323[医药卫生—卫生事业管理]