住院病案首页由电子病历系统和编码员审核对数据质量的影响  

Influence of the First Page of Hospitalized Medical Records Examined by Electronic Medical Record System and Coders on Data Quality

作　　者：赵欣[1] Zhao Xin(Medical Record Department,Beijing Obstetrics and Gynecology Hospital,Capital Medical University,Beijing 100026,China)

机构地区：[1]首都医科大学附属北京妇产医院病案室,北京市100006

出　　处：《中国病案》2020年第12期21-24,共4页Chinese Medical Record

摘　　要：目的探讨电子病历系统和编码员对于住院病案首页数据质量的审核,进一步提高住院病案首页数据质量。方法使用数字法从某院病案信息系统中调取2018年7月1日-2018年12月31日期间出院的300份病案资料作为对照组;调取2019年1月1日-2019年6月30日期间出院的300份病案资料作为观察组。自2019年1月1日开始由电子病历系统对住院病案首页信息中患者信息和住院信息填写的完整性进行审核,编码员对住院病案首页中医疗信息填写的准确性进行审核,发现问题及时与主管医师沟通确认并完善。由病案科组织专家针对对照组及观察组的住院病案首页数据质量进行检查。结果观察组患者信息填写完整率从84.33%提升到100%;诊疗信息填写准确率由80.67%提升到98.67%;观察组其他重要信息准确率由93%提升到99%,P<0.05,差异具有统计学意义。结论电子病历系统自检和病案科编码员对于住院病案首页数据质量的审核能加大信息完整性和正确性,是提高病案首页填写质量的一种有效方法。Objective To explore the audit of the data quality of the first page of hospital medical records by electronic medical record system and coders, so as to further improve the data quality of the first page of hospitalized medical records. Methods The front page data of medical records from July 1 to December 31, 2018 and from January 1 to June 30, 2019 were collected. 300 copies were taken as the pre quality control group in 2018 and 300 copies in 2019 as the post quality control group. The quality control experts checked the completeness of the basic information of patients, the accuracy of diagnosis and treatment information and the completeness of inpatient information on the home page, and compared the completeness of patient information, diagnosis and treatment information and inpatient information before and after quality control.The quality control method of the medical record department is mainly to check the items filled in the front page item by item by the coder, contact the clinic in time if any problem is found, and modify it within 3 days. Results The integrity rate of information filling in the group after quality control was higher than that in the group before quality control, and the integrity rate increased from 84.33% to 100%. The accuracy rate of the post quality control group was higher than that of the pre quality control group, and the accuracy rate was increased from 80.67% to 98.67%. The complete rate of the inpatient information in the post quality control group was higher than that in the pre quality control group, and the complete rate was increased from 93% to 99%, P<0.05. The difference is statistically significant. Conclusion The self-examination of the electronic medical record system and the examination of the data quality of the first page of the medical record by the encoder of the medical record department can increase the integrity and correctness of the information, which is an effective method to improve the quality of filling in the first page of the medical record.

关 键 词：住院病案首页 质量 编码员 审核 

分 类 号：R197.323[医药卫生—卫生事业管理]