两统计口径住院手术工作量差异原因分析  

The Reason Analysis on the Differences of the Number of Operations between the Two Statistical Calibers

作　　者：黄昊[1] 邓应梅[1] 刘春玲[1] 肖蓓[1] 仇叶龙[1] 李小莹[1] 赵琳[1] 董爱然[1] 

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2017年第9期71-73,共3页Chinese Medical Record

摘　　要：目的对病案首页系统和手术麻醉系统的两统计口径住院手术工作量差异进行客观描述,并分析原因,为医院管理者提供决策的线索和依据,提出相应的对策建议。方法分别按出院时间从病案首页系统和按手术时间从手术麻醉系统中调取2016年1月1日至31日的心脏科、骨科、疼痛科三个科室的手术记录相关信息,将两统计口径的手术工作量进行比对,采用描述统计方法分析差异。结果心脏科、骨科和疼痛科的手术工作量差异主要原因分别是手术麻醉系统的心脏手术均属于心外病区但一部分手术患者在病案首页系统中属于心内病区出院(83.33%),部分未入院的急诊骨科患者在病案首页系统中无出院记录但于手术麻醉系统显示在中心手术室做手术(53.16%),手术麻醉系统中患者的手术(如颈椎旁神经阻滞术)在病案首页系统按照北京临床版ICD-9-CM的手术操作类型为治疗性操作(44.44%)。结论差异主要原因包括门急诊患者未住院而做手术、时间检索方式不一致、手术操作定义归类不一致、同次住院多次手术等。针对原因进行改进,规范统计口径,提高管理决策的精准程度。Objectives To conduct objective description on the hospital operations workload differences between two statistical calibers based on medical record front pages system and surgical anesthesia system, analyze the reasons, provide clues and basis for hospital managers, and put forward the corresponding countermeasures and suggestions. Methods To search operation data from the medical record front pages system according to the discharging time and surgical anesthesia system according to the operation time from the three ＇departments of cardiology, orthopedic and pain from 1st to 31st January 2016, then match the operations workload data between two statistical calibers, then use describing statistical methods to analyze the differences. Results Main reasons of the surgery workload difference in cardiology, orthopedics and pain departments were separately changing department problems （83.33%）, surgery places problems （53.16%） surgery classification problems （44.44%）. Conclusions The main reasons for the differences included the type of patients, the way of time data collection, the inconformity classification between surgery and operation and the multiple surgeries of the patients. We should standardize the statistics so as to improve the accuracv of management decision.

关 键 词：病案首页 手术麻醉系统 统计口径 差异分析 

分 类 号：R197.323[医药卫生—卫生事业管理]