北京市三级医疗机构门诊病案首页上报质量评价  

The Evaluation of the Report Quality of the First Page of the Outpatient Medical Records for Tertiary Hospitals in Beijing

作　　者：郑建鹏 郝一炜 郭默宁 潘轶竹[3] 王天奇 ZHENG Jianpeng;HAO Yiwei;GUO Moning;PAN Yizhu;WANG Tianqi(Beijing Municipal Heaith Commission Information Center,Beijing 100034,China)

机构地区：[1]北京市卫生健康委信息中心(北京市卫生健康委员会医疗管理数据质量控制与改进中心),北京市100034 [2]首都医科大学附属北京地坛医院,北京市100015 [3]首都医科大学附属北京安定医院,北京市100120

出　　处：《中国卫生信息管理杂志》2021年第5期610-613,共4页Chinese Journal of Health Informatics and Management

基　　金：临床专科住院医疗服务绩效评价的DRGs信息化模型研究与应用(项目编号:首发2016-2-3051)。

摘　　要：目的构建门诊病案首页质量评价指标与方法。方法以北京市30家三级医疗机构2017年度的数据为基础,围绕首页数据上报的及时性和准确性设立指标,利用赋权综合打分方法,量化评价医疗机构门诊病案首页上报质量。结果获取了各家医疗机构上报的数据,对各家医疗机构病案首页数据上报的及时性和准确性进行评分,直观反映出在门诊病案首页上报工作中存在的问题。结论本研究设立的评价指标,在实际工作中有较强的科学性和可操作性,便于向各医疗机构反馈问题,可为提高数据质量、服务医改监测政策研究工作奠定基础。Objective To build up the evaluation system for the first page of the outpatient medical records.Method An indicator system consist of timeliness and accuracy of the first page is built by the data of 30 hospitals in Beijing,and weighted score method is used to do the quality evaluation.Result By the data reported by each medical institution,the timeliness and accuracy of the data reported by the first page of medical records in each medical institution are scored,which intuitively show the problems existing in practice.Conclusion The indicator system set in this paper is reasonable and workable in practice,which could feedback the problems to hospitals,improve the quality of data,and make better service for the medical reform.

关 键 词：门诊病案首页 病案质量 评价指标 医改监测 

分 类 号：R-058[医药卫生] R319