河南省三级公立医院病案首页质控情况分析  

Quality analysis of homepage data of inpatient cases of public tertiary hospitals in Henan Province

作　　者：刘新奎[1] 杨林朋[1] 尚小平[1] 董一超 Liu Xinkui;Yang Linpeng;Shang Xiaoping;Dong Yichao(The First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,China)

机构地区：[1]郑州大学第一附属医院,河南郑州450052

出　　处：《中国医院统计》2020年第3期272-274,279,共4页Chinese Journal of Hospital Statistics

基　　金：河南省医学科技攻关省部共建项目(SB201901021)。

摘　　要：目的了解河南省三级公立医院病案首页质控情况,为顺利开展公立医院绩效考核及DRG工作打下基础。方法河南省病案质量控制中心在全省范围内开展了病案管理情况调查,通过河南省病案质控平台收集河南省三级公立医院2018年全年住院病案首页数据,从首页质控情况、首页质控方式、首页质量评分方面进行分类统计分析。结果 (1)数据显示,62.7%的三级公立医院已经开展病案首页质控工作,其中省级专科医院开展首页质控工作情况优于省级综合医院(χ~2=4.047,P=0.044);(2)住院病案首页质控采用手工方式的医院占39.2%,采用信息化方式的医院占23.5%,其中市级综合医院病案首页质控的信息化程度优于市级专科医院;(3)结果显示省级和市级和综合医院首页质量均优于同级专科医院(t=2.784,P=0.021;t=2.238,P=0.033)。结论加强检查、督导力度,促进各级医院重视病案首页质控工作,实现三级公立医院精细化、信息化管理,提高病案首页质量。Objective To understand the quality control situation on the front page of medical records of public tertiary hospitals in Henan Province,and lay a foundation for the smooth performance appraisal and DRG work of public hospitals.Methods Henan Provincial Center for Quality Control of Medical Records conducted a survey on the management of medical records across the province.Through the Henan Provincial Platform for Medical Record Quality Control,we collected the home page data of hospitalization records of public tertiary hospitals in Henan Province in 2018,and made a classified statistical analysis from the home page quality control situation,home page quality control method and home page quality score.Results(1)Data showed that 62.7%of public tertiary hospitals have carried out the quality control work on the front page of medical records,among which provincial specialized hospitals were significantly better than provincial general hospitals(χ2=4.047,P=0.044).(2)The hospitals that adopted manual quality control on the first page of medical records accounted for 39.2%,and the hospitals that adopted information method accounted for 23.5%,among which municipal general hospitals were better than municipal specialized hospitals in information of homepage quality control.(3)the results showed that the quality of the front page of general hospitals was significantly better than that of specialist hospitals(t=2.784,P=0.021;t=2.238,P=0.033).Conclusion Inspection and supervision should be strengthened to promote hospitals at all levels to pay attention to the quality control of the first page of medical records,realize the refinement and information management of public tertiary hospitals,and improve the quality of the first page of medical records.

关 键 词：住院病案首页 病案质控 质量评分 

分 类 号：R197.323.1[医药卫生—卫生事业管理]