病案首页填写中人为因素对HQMS数据的影响  

The Influence of Man-made Factors in the Front Sheet of Medical Record Filling to the Data of HQMS

作　　者：张红[1] 韦秀碧[1] 朱铭[1] 

机构地区：[1]遵义医学院附属医院病案管理科,遵义市563003

出　　处：《中国病案》2014年第8期12-14,共3页Chinese Medical Record

摘　　要：目的根据某院初步对病案首页填写进行整改的情况以分析其对HQMS数据质量的影响,从而制定相应的管理措施,以提高HQMS数据的提取质量。方法采集2013年9月-11月(整改前)和2013年12月至2014年1月-2月(整改后)出院病案首页信息进行统计分析。结果部分HQMS数据指标经该院初步整改后有明显改善,如重点手术麻醉分级漏填率由12.80%降至9.61%(X2=4.84,P<0.05),输血反应填写差错率由2.69%降至0.88%(2?=22.20,P<0.05),手术并发症信息填写差错率由2.33%降至0.88%(X2=43.66,P<0.05);但也有部分指标整改后仍未见明显改善。结论规范、准确填写病案首页信息是HQMS数据质量的重要保障,正确填写病案首页对提高HQMS数据质量具有关键作用。Objective To analyze the influence of the preliminary rectification of the front sheet of medical record filling to the data of HQMS for proposing corresponding management measures to improve the quality of HQMS. Methods Data about the front sheet of medical record were collected and carried out a statistical analysis, which before rectification were between September and November in 2013 and which after rectification were between December in 2013 to January and February in 2014. Results There were statistically significant improvement in some data of HQMS after rectification. Such as the no-filling rate of the grade of surgery anesthesi, which fell from 12. 80% to 9. 61 （x^2=4. 84, P〈0. 05）; the error probability of blood transfusion reaction, which fell from 2. 69% to 0. 88% （ x^2 =22. 20, P〈0. 05） ; the error probability of surgical complications, which fell from 2. 33% to 0. 88% （ x^2 =43.66, P〈 0. 05）. But some data of HQMS after rectification were no statistically significant improvement. Conclusion The standard and accurate filling out of the front sheet of medical record is the important guarantee for the quality of the data of HQMS. The filling quality of the front sheet of medical record played a positive role in improving the quality of the data of HQMS.

关 键 词：病案首页 人为因素 HQMS数据 影响 

分 类 号：R197.323[医药卫生—卫生事业管理]