病案首页的HQMS网络直报错误分析及改进研究  

Error Analysis and Improvement of HQMS Direct Network Reports of the Front Sheet of Medical Records

作　　者：张锦平[1] 赵敏[1] 张建华[1] 

机构地区：[1]云南省肿瘤医院(昆明医科大学第三附属医院)病案管理科,昆明市650018

出　　处：《中国病案》2015年第10期24-24,48,共2页Chinese Medical Record

摘　　要：目的规范病案首页填写,提高HQMS网络直报的准确性。方法利用上CMIS软件和HQMS自带的审核功能,回顾性地分析某三甲医院2013年7月-2014年12月所有病案首页的日报错误。结果 80 221份病案首页中,81 783份上报成功,达到A级接口标准。1562份病案首页出现报错,所占比例依次为病案首页基本情况漏填(36.17%)、出院诊断填写错误(27.66%)、病案首页重复入库的病案(22.15%),病案首页逻辑性信息错(11.72%)。结论医务部应加强医师、编码员、HQMS网络直报员的监督和培训,建立院科两级质量监管体系,从数据产生的源头和终末阶段提高HQMS上报的准确性。Objective To standardize the front sheet of medical records fill in, improve the accuracy of the HQMS direct network reports. Methods The Daily report errors in the front sheet of medical records were analyzed retrospectively from July, 2013 to December 2014 in a grade 3 and first-class hospital by Using the CMIS software and HQMS auditing. Results There were 80221 front sheets of medical records, 81783 reported successes, had achieved A level. 1562 Appeared errors： basic information not filling（36.17%）, discharge diagnoses fill in error（27.66%）, repeated storage（22.15%）, and logic information fault（11.72%）. Conclusion Medical department should strengthen the supervision and training of the physicians, coders, HQMS network direct report staffs. Establish quality supervision system between hospital and departments; improve the accuracy of the HQMS reports from the data source and terminal stage.

关 键 词：HQMS 病案首页 日报错误 改进措施 

分 类 号：R197.323[医药卫生—卫生事业管理]