某市二级及以上医保定点医疗机构住院病案首页填报质量基线调查  

Quality Baseline Survey on the Front Page of Inpatient Medical Records in Designated Medical Institutions with Secondary and Above Medical Insurance in a City

作　　者：岑朝[1] 覃焱 吴艳秀 叶颖霞 农小珍[2] 马俊倩 禤中平[1] 廖崧辰 唐雪冰 Cen Chao;Qin Yan;Wu Yanxiu;Ye Yingxia;Nong Xiaozhen;Ma Junqian;Xuan Zhongping;Liao Songchen;Tang Xuebing(Quality Management Office,Affiliated Hospital of Youjiang Medical University for Nationalities,Baise City,Guangxi Zhuang Autonomous Region,533000,China;不详)

机构地区：[1]右江民族医学院附属医院质量管理办公室,广西壮族自治区百色市533000 [2]右江民族医学院附属医院病案科,广西壮族自治区百色市533000

出　　处：《中国病案》2023年第11期6-9,共4页Chinese Medical Record

基　　金：广西壮族自治区卫生健康委员会自筹经费计划课题(Z20180194)。

摘　　要：目的对某市二级及以上医保定点医疗机构住院病案首页质量进行基线调研,为进一步提高医保定点医疗机构住院病案首页填写质量提供依据。方法2021年9月26日-2021年9月30日抽查39家二级及以上医保定点医疗机构2021年6月1日当天出院患者,按出院顺序前50份住院病案首页,组织专项检查组,按照国家卫生健康委《住院病案首页填报质量评价标准》进行评价。结果抽查住院病案首页1891份,平均分为94.80分,各类医院住院病案首页填报质量评分从高到低为专科医院(97.11±1.77)分、西医综合医院(95.59±3.20)分、中医医院(94.59±2.67)分、妇幼保健医院(93.43±5.43)分;三级医院(96.44±1.76)分,二级医院(94.56±4.01)分;医师主要诊断选择正确率平均为84.08%,编码正确率平均为84.14%。结论某市各类各级医保定点医疗机构住院病案首页填报质量参差不齐,总体水平较低,需要采取措施进一步提升。Objectives This study aims to conduct a baseline survey on the quality of the front page of inpatient medical records in designated medical institutions of secondary and above medical insurance in a city,so as to provide a basis for further improving the quality of filling in the front page of inpatient medical records in the medical institutions designated by medical insurance.Methods From September 26,2021 to September 30,2021,patients who discharged from 39 medical institutions designated by the second-level and above medical insurance on June 1,2021 were randomly inspected.The first 50 inpatient medical records were listed in the order of discharge,which would be evaluated by organizing a special inspection team according to the National Health Commission's"Quality Evaluation Standards for Filling in the First Page of Inpatient Medical Records".Results A total of 1,891 front pages of inpatient medical records were randomly checked,with an average score of 94.80 points.The quality scores of the front pages of inpatient medical records in various hospitals from high to low were specialized hospitals(97.11±1.77),general hospitals of western medicine(95.59±3.20),traditional Chinese medicine hospitals(94.59±2.67),and maternal and childcare hospitals(93.43±5.43)points;Grade III hospitals had(96.44±1.76)points and grade II hospitals had(94.56±4.01)points;The average correct rate of physicians'main diagnosis selection was 84.08%,and the average correct rate of coding was 84.14%.Conclusions The quality of the front pages of inpatient medical records in designated medical institutions of various levels of medical insurance in a city is still uneven,and the overall level is still low.Measures need to be taken to further improve the quality.

关 键 词：住院病案首页 抽样调查 质量 疾病分类编码 

分 类 号：R197.323[医药卫生—卫生事业管理]