某市35家医院住院病案首页填写质量分析及对策  

Quality Analysis and Countermeasures of Inpatient Medical Record Front Page Filling in 35 Hospitals in a City

作　　者：王珊[1] 朱雨菲 李强[1] 余唯 罗明春[1] Wang Shan;Zhu Yufei;Li Qiang;Yu Wei;Li Wei(Zigong Medical Record Quality Control Center,Zigong Fourth People's Hospital,Zigong 643000,Sichuan Province,China;不详)

机构地区：[1]自贡市第四人民医院(自贡市病案质控中心),四川省自贡市643000

出　　处：《中国病案》2023年第2期17-21,共5页Chinese Medical Record

基　　金：四川省自贡市重点科技计划项目(2019ZC18)。

摘　　要：目的 分析某市35家医院住院病案首页质量现状,找到存在的主要问题,提出改进措施,提高全市住院病案首页质量。方法 市病案质控中心组织市病案专业委员会专家组成员40名随机抽查某市公立医院22家、民营医院11家,其中三级医院10家、二级医院12家、一级医院2家、未评级医院2家共计840份2021年1月1日-2021年3月31日期间的出院病案首页,并按照国家卫生健康委《住院病案首页数据填写质量规范(暂行)》《住院病案首页数据质量管理与控制指标(2016版)》的要求进行检查评分,检查结果应用SPSS 17.0软件进行统计分析,描述性分析用百分位数和构成比表示,采用Kruskal-Wallis H检验,以P<0.05为差异有统计学意义。结果 840份住院病案首页平均得分为96.90分,中位数为97.50分,P25=95.50,P75=99。三级医院住院病案首页质量最高,二级医院次之(χ^(2)=165.809,P=0.000);妇幼保健院质量最高,综合医院次之,最差为康复医院(χ^(2)=165.809,P=0.000);营利性医院质量高于非营利性医院(χ^(2)=44.858,P=0.000)。840份抽检病案共发生缺陷频次1394次,其中患者基本信息513次(占36.8%)、住院过程信息117次(占8.39%)、诊疗信息493次(占35.37%)、三级医师质控签名211次(占15.14%)、费用信息60次(占4.30%)。结论 受病案信息系统、质控机制及规范掌握等因素影响,全市住院病案首页中前三位缺陷为患者基本信息、诊疗信息以及三级医师质控签名。不同级别医院缺陷分布有差异,三级医院患者基本信息缺陷最多,一级、二级及未评级医院在诊疗信息和三级医师质控签名方面的缺陷占比最高。Objectives To analyze the current situation of the quality of the inpatient medical record homepage in 35 hospitals in a city, find out the main problems, and put forward improvement measures to improve the quality of the inpatient medical record front page in the city. Methods The municipal medical records quality control center organized 40 expert members of municipal medical records Professional Committee to randomly check the front pages of 840 discharged medical records from 22 public hospitals and 11 private hospitals in a city, including 10 tertiary hospitals, 12 secondary hospitals, 2 first-level hospitals and 2 unrated hospitals from January 1st, 2021 to March 31st, 2021. The inspection and score were performed according to the requirements of the National Health Commission "Quality Specification for Filling in the Data of the Front Page of Inpatient Medical Records(Interim)" and "Data Quality Management and Control Index of the Front Page of Inpatient Medical Records(2016 edition)".SPSS 17.0 software was used for statistical analysis of the inspection results, and the descriptive analysis was expressed by percentile and component ratio. Kruskal-Wallis H test was used, and P<0.05 was considered statistically significant. Results The average score of the front page of 840 inpatient medical records was 96.90, the median score was 97.50, P25=95.50, P75=99. The quality of the front page of inpatient medical records in tertiary hospitals was the highest, followed by that in secondary hospitals(χ^(2)=165.809, P=0.000). The quality of maternal and child health hospital was the highest, followed by general hospital, and the worst was rehabilitation hospital(χ^(2)=165.809, P=0.000). The quality of for-profit hospitals was higher than that of non-profit hospitals(χ^(2)=44.858, P=0.000). A total of 1394 defects occurred in 840 sample medical records, including 513 patients’ basic information(36.8%), 117 patients’ hospitalization process information(8.39%), 493 patients’ diagnosis and treatment information(

关 键 词：住院病案首页 缺陷 质量分析 改进措施 

分 类 号：R197.323[医药卫生—卫生事业管理]