公立医院绩效考核背景下病例档案首页填写常见问题及应对措施  

Common Problems and Countermeasures for Filling in the Home page of Case Files under the Background of Performance Appraisal in Public Hospitals

作　　者：于强 马科[2] 王凌芳 于砚丽[4] YU Qiang;MA Ke;WANG Lingfang;YU Yanli(Department of Patriotic Health,Weifang Health Development Service Center,Weifang,Shandong Province,261061 China;Department of Otolaryngology,80th Army Hospital of the Chinese People's Liberation Army,Weifang,Shandong Province,261000 China;Department of Medical Record Statistics,Linqu County People's Hospital,Weifang,Shandong Province,262600 China;Department of Otolaryngology,Weifang People's Hospital,Weifang,Shandong Province,261041 China)

机构地区：[1]潍坊市卫生健康发展服务中心爱国卫生科,山东潍坊261061 [2]中国人民解放军陆军第八十集团军医院耳鼻喉科,山东潍坊261000 [3]临朐县人民医院病案统计科,山东潍坊262600 [4]潍坊市人民医院耳鼻喉科,山东潍坊261041

出　　处：《中国卫生产业》2022年第10期55-58,共4页China Health Industry

基　　金：山东省潍坊市卫健委科研项目(WFWSJK-2022-060)。

摘　　要：三级公立医院绩效考核作为国家深化医改的重点内容,是推进现代化医院管理的重大措施,准确及时且完整地填报病例档案首页信息则是医院信息统计的重要工作。病例档案首页已经被纳入公立医院等级评审的绩效考核,其信息的准确与否直接关系到医院绩效。作为患者就诊过程的核心信息,其质量高低与科室工作指标完成情况以及医院针对各医疗数据统计之间有显著相关性,直接关系到医疗管理的质量水平。病例档案首页的数据质量关系到医疗质量管理水平,要求公立医院每月定时上传病例档案首页相关信息,并由上级主管部门及时反馈所存在问题,达到有效监测医院医疗质量,促进医院及时发现问题并整改,提高临床诊疗质量的目的。The performance appraisal of tertiary public hospitals,as the key content of deepening medical reform in the country,is a major measure to promote modern hospital management.Accurate,timely and complete reporting of the homepage information of medical records is an important task of hospital information statistics.The homepage of medical records has been included in the performance appraisal content of public hospital grade review,and the accuracy of its information is directly related to hospital performance.As the core information of the patient's medical treatment process,its quality has a significant correlation with the completion of the department's work indicators and the hospital's statistics on various medical data,which is directly related to the quality of medical management.The data quality of the front page of medical record files is related to the level of medical quality management.Public hospitals are required to upload the relevant information on the front page of medical record files on a monthly basis,and the higher-level subjective departments should timely feedback the existing problems,to effectively monitor the medical quality of the hospital,promote the hospital to detect problems in a timely manner,rectify and stabilize,and improve the quality of clinical diagnosis and treatment.

关 键 词：病例档案首页 质量控制 公立医院 绩效考核 

分 类 号：R197.32[医药卫生—卫生事业管理]