住院病案首页基本信息的专项质控及改进效果  

Special Quality Control and Improvement Measures of Basic Information on the Front Pages of Medical Records

作　　者：江丽凤[1] 文建珍[1] 陆白洁 叶丽华[1] 徐素梅[1] Jiang Lifeng;Wen Jianzhen;Lu Baijie;Ye Lihua;Xu Sumei(The fifth Affiliated Hospital of Sun Yat-sen University,Zhuhai 519000,Guangdong Province,China;不详)

机构地区：[1]中山大学附属第五医院,广东省珠海市519000

出　　处：《中国病案》2020年第5期21-23,共3页Chinese Medical Record

摘　　要：目的分析某医院住院病案首页基本信息缺陷情况,提出改进措施。方法2019年7月通过对住院收费处人员进行病案首页基本信息填写的培训,回顾性核查某院培训前2019年6月1日-2019年6月30日的6252份和培训后2019年8月1日-2019年8月31日的7633份出院患者病案首页基本信息,将缺陷信息按缺陷类型进行归类总结、统计,分析培训前后缺陷率的差别。结果住院患者基本信息培训前的缺陷率为8.97%,培训后为5.35%,明显下降,差别具有统计学意义(χ^2=69.682,P<0.001),其中现住址不在标准地址库内、婚姻与联系人关系矛盾、年龄与关系不符、基本信息的其它空项缺陷均有明显下降,差别均具有统计学意义。结论住院病案首页信息填写不完整现象较严重,培训后总体缺陷率明显降低,应采取加强住院收费处人员的培训、利用二代身份证读卡器读入患者的基本信息、提升病案信息系统功能等措施,提高住院病案首页基本信息的质量。Objective To analyze the detect ot the basic information ot the tront pages ot medical records in the hospital and provide optimization proposal.Methods In July 2019 through to the hospital as cashier personnel training of basic information to fill in front page,retrospective reviewed the discharged patients’front pages basic information of 6252 cases in a hospital from June 1 st,2019 to June 30 th,2019,and 7633 cases from August 1 st,2019 to August 31 st,the defect information according to the defect types were classified summary,made statistic,and analyzed the difference between the defect rate of before and after the training.Results The defect rate of basic information of inpatients in August 2019 was significantly lower than that in June 2019,and the difference was statistically significant(χ^2=69.682,P<0.001).The defect rate of that the current address was not in the standard address database,the marriage and contact relationship were contradictory,the age and relationship were inconsistent,and other gaps in basic information were significantly decreased,and the difference was statistically significant.Conclusions The incomplete information on the front pages of inpatient medical records was serious,and the overall defect rate was significantly reduced after training.Measures should be taken to improve the quality of the front pages of inpatient medical records by strengthening the training of the staff of the inpatient medical records office,reading the basic information of patients with the second-generation id card reader,and improving the function of the medical records information system.

关 键 词：住院病案首页 基本信息 专项质控 改进措施 

分 类 号：R197.323[医药卫生—卫生事业管理]