住院病案首页操作信息自动提取的实践  

Practice of Automatic Extraction of Operation Information in Front Pages of Hospitalized Medical Records

作　　者：郝育鹏[1] 季新强[1] 王彦晨 刘晶[1] Hao Yapeng Ji Xinqiang Wang Yanchen Liu Jing(Key Laboratory of Carcinogenesis and Translational Research （Ministry of Education）, Department of Medical Records and Statistics, Peking University Cancer Hospital ＆ Institute, Beijing 100142, China)

机构地区：[1]北京大学肿瘤医院暨北京市肿瘤防治研究所病案统计室,恶性肿瘤发病机制及转化研究教育部重点实验室,北京市100142

出　　处：《中国病案》2017年第7期44-46,共3页Chinese Medical Record

摘　　要：住院病案首页信息对医院管理和医教研工作均具有重要价值。为进一步提高首页填报质量,减少操作填报的"漏报、错报"问题,某院开展了病案首页操作信息自动提取工作。在对现行北京市医疗机构物价收费目录和ICD-9-CM-3 6.0手术操作字典库进行梳理的基础上,明确了物价收费项目与住院病案首页操作信息的对应关系,并通过信息系统予以关联,临床医师在填报首页时通过点击"提取操作",即可实现患者此次住院期间所有操作信息的自动提取。在北京市医管局对该院住院病案首页填报准确率的检查中,"其他手术/操作"填报准确率由2014年的75.51%提高至2016年的100.00%。住院病案首页操作信息自动提取提高了临床医师首页填报的效率和准确率,促进了病案首页填报质量的持续。The front pages information of inpatient medical records is of great value to hospital administration and medical teaching and research. In order to further improve the quality of front pages reporting and reduce the ＂missing report＂ and ＂wrong reporting＂ problem, a hospital has carried out the automatic extraction of medical record operation information. On the basis of analyzing the current medical institutions of Beijing city price toll directory and ICD-9-CM3 6.0 operation dictionary, the charging items associated with medical records of the operation information, and through the information system to be associated, clinicians in completing the firs! page by clicking on the ＂when the extraction operation, can realize the automatic extraction of patients all operation information during hospitalization. This work greatly improves the efficiency and accuracy of the front pages of the clinician and promotes the quality of the first page of the medical record. In the examination of the accuracy rate of the first page of medical records in the hospital of Beijing Hospital Authority, the accuracy rate of ＂other operations / operations＂ was increased from 75.51% in 2014 to 100% in 2016. This article discusses the implementation plan, the implementation effect and the deficiency of the ＂automatic extraction of medical record homepage operation information＂ in this hospital, so as to provide reference for further improving the quality of the front pages of medical records.

关 键 词：住院病案首页 操作信息 自动提取 

分 类 号：R197.323[医药卫生—卫生事业管理] TP391.1[医药卫生—公共卫生与预防医学]