信息化建设对病案首页数据质量的影响  

The influence of informatization construction on the data quality of the first page of medical records

作　　者：王可可[1] WANG Keke(Jilin People s Hospital,Jilin City,Jilin Province,132001,China)

机构地区：[1]吉林市人民医院,吉林吉林132011

出　　处：《吉林医药学院学报》2023年第2期104-107,共4页Journal of Jilin Medical University

摘　　要：目的分析信息化建设对病案首页数据质量的影响。方法选取2020年1月-6月间1000份病案首页信息作为参照组,行常规管理;选取2020年7月-12月间1000份病案首页信息作为研究组,予以信息化管理。比较应用效果。结果研究组信息填写缺陷率低于参照组(P<0.05);疾病即手术操作编码不准确、病患基本信息缺失、临床路径误填或漏填等工作失误发生率低于参照组(P<0.05);病案首页数据质量评分高于参照组(P<0.05)。结论信息化建设对病案首页数据质量产生积极影响,有利于降低信息填写缺陷率,减少工作失误,提高病案首页数据质量,为临床医疗服务提供准确数据,具有推广价值。Objective To analyze the impact of information construction on the quality of the first page data of medical records.Methods The first page information of 1000 medical records from January to June 2020 was selected as the reference group for routine management;The first page information of 1000 medical records from July to December 2020 was selected as the research group for information management.Compare the application effect.Results The rate of information filling defects in the study group was lower than that in the reference group(P<0.05);The incidence of work errors such as inaccurate surgical operation code,lack of basic patient information,and incorrect or missed clinical path filling in the disease group was lower than that in the reference group(P<0.05);The quality score of the first page of the medical record was higher than that of the reference group(P<0.05).Conclusion Informatization construction has a positive impact on the data quality of the first page of the medical record,which is conducive to reducing the rate of information filling defects,reducing work errors,improving the data quality of the first page of the medical record,and providing accurate data for clinical medical services.It is worth popularizing.

关 键 词：信息化建设 病案首页数据 缺陷率 质量评分 

分 类 号：R197.32[医药卫生—卫生事业管理]