病案统计管理信息系统的病案首页数据质量控制  

Data quality control of medical record homepage in medical record statistics management information system

作　　者：杨宏橼 陈丽容[1] 黎思勤 邹慧 陈伯宁[1] Yang Hongyuan;Chen Lirong;Li Siqin;Zou Hui;Chen Boning(Sun Yat-sen Memorial Hospital of Sun Yat-sen University,Guangdong Guangzhou 510120)

机构地区：[1]中山大学孙逸仙纪念医院,广东广州510120

出　　处：《中国社区医师》2021年第26期191-192,共2页Chinese Community Doctors

摘　　要：目的:加强医疗机构病案首页质量管理,提升病案首页数据质量,为三级公立医院绩效改革考核医疗评价和医保支付方式改革提供支持。方法:研究2018年1月-2019年12月病案统计管理系统中病案首页数据存在的质量问题,分析错误原因,有针对性地制定改进措施,将改进前和改进后的病案首页质量进行比较,检验病案首页的质量控制措施是否有效。结果:改进后的病历首页错误数量明显少于改进前,病历首页数据质量得到提升。结论:病案首页数据质量控制是一个多部门参与,多环节共同改进的工作,需要建立一套标准完善的质控流程,不断优化,巩固工作成果。Objective:To strengthen the quality management of medical record homepages in medical institutions,improve the data quality of medical record homepages,and provide support for the reform of medical evaluation of performance reform and assessment and payment mode of medical insurance in tertiary public hospitals.Methods:To study the quality problems of medical record homepages data in the medical record statistical management system from January 2018 to December 2019,analyze the reasons for errors,formulate targeted improvement measures,and compare the quality of the medical record homepages before and after the improvement,check whether the quality control measures on the first page of the medical record are effective.Results:The number of errors on the medical record homepages of the improved medical record was significantly less than that before the improvement,the data quality of medical record homepages was improved.Conclusion:The data quality control of the medical record homepage is a work involving multiple departments and multiple links for joint improvement.It is necessary to establish a set of standard and complete quality control procedures,continuously optimize,and consolidate the work results.

关 键 词：病案首页 质量控制 管理 

分 类 号：R197.323[医药卫生—卫生事业管理]