多维分析法在住院病案首页数据质量评价中的应用  

Application and Evaluation of the Multidimensional Analysis on the Data Quality of the Medical Records Front Pages

作　　者：黄利娟[1] 查君敬 梁学柱[1] 伯伟[1] 周和平[1] 杨延国[1] Huang Lijuan;Zha Junjing;Liang Xuezhu;Bo Wei;Zhou Heping;Yang Yanguo(Anqing Hospital Affiliated to Anhui Medical University,Anqing 246003,Anhui Province,China;不详)

机构地区：[1]安徽医科大学附属安庆医院,安徽省安庆市246003

出　　处：《中国病案》2021年第2期18-21,共4页Chinese Medical Record

摘　　要：目的利用多维分析法对住院病案首页数据质量进行评价,以形成科学、系统的住院病案首页质控管理模式,提升住院病案首页填写质量。方法对某三甲医院2019年1月至12月的住院病案按照随机数字表法抽取3000份,采用多维分析法,从住院病案首页填报的完整性、准确性、住院病案首页优质率三个方面进行分析。结果该院住院病案首页数据的完整率、准确率及住院病案首页质量优质率分别为92.40%,96.03%和91.80%。住院病案首页中缺失较多的项目为RH血型、ABO血型、是否有31天再入院计划等;错误较多的项目为主要诊断、主要手术及操作及主要诊断、主要手术及操作编码。其中内科系统及重症医学科完整率高于外科系统,内科系统正确性及住院病案首页优质率高于外科系统和重症医学科,差异均有统计学意义(均P<0.05)。结论多维分析方法是住院病案首页数据质量控制的重要辅助工具,可为临床及医院管理人员进行住院病案首页数据质量控制提供科学的依据。Objective To analyze the application of Multidimensional analysis on the data quality of the Medical records front pages and form a scientific and systematic quality control system of the medical records front pages,to improve the quality of the medical record front pages.Methods Multidimensional analysis was used to analyze the quality of 3000 discharged medical records data from the 2019 year of a three class hospital,which were chosen by random number table method,and the data was analyzed from three aspects of integrity,accuracy and the excellent rate of data quality on the medical records front pages.Results Integrity rate,accuracy rate and the excellent rate of data quality of data quality on the medical records front pages were 92.40%,96.03%and 91.80%respectively.The items missing in the front page of the medical record were Rh blood group,ABO blood group and whether there was a 31 day re admission plan.The items with more errors were main diagnosis,main operation and operation,main diagnosis,main operation and operation code.The integrity rates of internal medicine and intensive care unit were higher than the surgery,the accuracy rate and the excellent rate of data quality on the medical records front pages of internal medicine were higher than the intensive care unit and the surgery(P<0.05).Conclusion Multidimensional analysis is of great help to improve the quality control of the medical records front page,and can provide scientific basis to the department of clinical and hospital management on improving the data quality of Medical record front pages.

关 键 词：多维分析法 住院病案首页 数据质量 

分 类 号：R197.323[医药卫生—卫生事业管理]