绩效考核背景下住院病案首页质量分析  

Analysis on the Front Pages of Medical Records under the Background of Performance Assessment

作　　者：徐露[1] 孙月鑫 陈亮[1] Xu Lu;Sun Yuexin;Chen Liang(Jiangsu Province Hospital,Nanjing 210039,Jiangsu Province,China)

机构地区：[1]江苏省人民医院,江苏省南京市210039

出　　处：《中国病案》2022年第7期18-20,共3页Chinese Medical Record

摘　　要：目的 分析基于公立医院绩效考核下的某省妇幼保健院住院病案首页数据填写存在的问题,查找原因并提出改进措施与建议。方法 按各科室1/3比例对2020年12月1日-2020年12月31日全院出院病案3120份进行系统抽样,由质控小组对1040份住院病案首页逐条检查,对缺陷项目进行统计分析。结果 抽查的住院病案首页总体缺陷率为21.9%,总缺陷项目达374个,错误前3名依次为:病理诊断填写(占13.4%)、主要诊断选择(占8.5%)、其他诊断(占7.5%);90%科室住院病案首页存在缺陷,缺陷率前3名为:乳腺科(占37.5%)、产科(占29.5%)、整形烧伤科(占23.7%);妇幼ICU病历未发现问题。结论 总体住院病案首页质量不容乐观,针对病理、诊断、手术错填漏填等情况,通过定期培训、完善信息化建设、加强行政管理提高住院病案首页质量,为绩效考核打下坚实的基础。Objectives This study aims to analyze the existing problems in the data entry of inpatient medical record from a provincial maternal and child health hospital based on the performance assessment of public hospitals,find the causes and put forward improvement measures and suggestions. Methods 3120 discharged medical records,which were composed of 1/3 medical records from each department in the entire hospital, from December 1,2020 to December 31,2020 were systematically sampled. The quality control team checked the front pages of 1,040inpatient medical records one by one to find out the defective items and perform statistical analysis. Results Based on the selective examination, the overall defect rate of the front pages of the inpatient medical records was 21.9%,and the total number of defective items reached 374. According to the statistics of error types, the top three errors were: errors of omission in pathology reports(13.4%), main diagnosis selection errors(8.5%) and other diagnostic omission errors(7.5%). According to department statistics, 90% of departments has defects on the medical record front pages. The departments with top three defect rates were galactophore department(37.5%),obstetrical department(29.5%) and department of burn and plastic surgery(23.7%). No existing problems was found in the medical records of maternal and child ICU. Conclusions The overall quality of the front pages of inpatient medical records is not optimistic. The results of this study suggest that regarding pathology, diagnosis and omission errors in surgical reports, the quality of the front pages of inpatient medical records need to be enhanced through regular training, improvement of information construction and strengthening of administrative management,in order to lay a solid foundation for the evaluation of performance.

关 键 词：住院病案首页 缺陷分析 质量控制 改进措施 

分 类 号：R197.323[医药卫生—卫生事业管理]