终末住院病案首页多环节质量监控  

Mmulti Link Quality Control in the Front Page of Final Medical Record

作　　者：张琴[1] 李晓东[1] 曹玉龙[1] 徐晓明[1] Zhang Qin;Li Xiaodong;Cao Yulong;Xu Xiaoming(Department of Medical Records Statistics,Western Hospital of Beijing Chaoyang Hospital Affiliated to Capital Medical University,Beijing,100043,China)

机构地区：[1]首都医科大学附属北京朝阳医院西院病案统计科,北京市100043

出　　处：《中国病案》2020年第4期31-33,44,共4页Chinese Medical Record

摘　　要：目的通过住院病案首页四级质控前后结果分析,探究提高终末住院病案首页质量的有效途径。方法分别提取2016年全年出院患者19 728份病案为四级法质控前数据作为对照组,2017年全年出院患者20 686份病案四级法质控后数据作为观察组,质控标准依据2016年6月,国家卫生计生委印发了《住院病案首页数据填写质量规范(暂行)》和《住院病案首页数据质量管理与控制指标(2016版)》及医院《病案首页评分标准(2016版)》等文件,将两组终末病案首页缺陷进行对比分析,并采用SPSS16.0统计软件对数据进行处理。结果 2016年度首页合格率为70.81%,2017年度经四级法质控住院病案首页后住院病案首页合格率为84.69%,终末住院病案首页总缺陷率下降13.88%,各主要住院病案首页质控缺陷项占比亦明显下降,均有统计学差异(P<0.001)。结论积极实施四级质控较传统单一模式的终末住院病案首页质控有着显著优势,使终末住院病案首页缺陷率明显下降,对提高整体住院病案质量有着重要意义。Objective Through the comparative analysis of the results before and after the implementation of the four level quality control method of the first page of medical records,to explore the effective ways to improve the quality of the first page of the final medical records.Methods In 2016,19728 medical records of all discharged patients were taken as the control group(before the four-level method of quality control),and in 2017,20686 medical records of all discharged patients were taken as the observation group(after the four-level method of quality control).The four-level quality control method is to move forward the quality control time of the first page of the inpatient medical record,from the running medical record to the final medical record,and from the clinical department to the functional department in four stages and levels,The quality control standard is based on June 2016,the national health and Family Planning Commission printed and distributed documents such as the quality specification for filling in the data on the front page of inpatient medical records(Provisional),the data quality management and control index on the front page of inpatient medical records(2016 version) and the scoring standard on the front page of medical records(2016 version) of our hospital.The defects on the front page of the two groups of final medical records were compared and analyzed,and SPSS 16.0 statistical software was used for logarithm analysis Accordingto.Results In 2016,the first page qualified rate was 70.81%.In 2017,the first page qualified rate was 84.69% after the first page of the four-level quality control medical record.The total defect rate of the first page of the final medical record decreased by 13.88%.The proportion of quality control defects of each main home page also decreased significantly,with statistical differences(P<0.001).Conclusions The active implementation of the quality control of the first page of the multi link medical record has a significant advantage over the traditional single mode of t

关 键 词：终末住院病案首页 四级 质量监控 提高 

分 类 号：R197.323[医药卫生—卫生事业管理]