病案首页信息质量控制在病案信息管理中的应用效果  

Application Effect of Information Quality Control on the First Page of Medical Records in Medical Records Information Management

作　　者：汤洁 杨敏[2] 王宏 TANG Jie;YANG Min;WANG Hong(Department of Information Medical Records Room,the 80th Group Military Hospital of Chinese People's Liberation Army,Weifang,Shandong Province,261000 China;Department of Urology,the 80th Group Military Hospital of Chinese People's Liberation Army,Weifang,Shandong Province,261000 China;Department of Neurosurgery V,Weifang People's Hospital,Weifang,Shandong Province,261000 China)

机构地区：[1]中国人民解放军陆军第八十集团军医院信息科病案室,山东潍坊261000 [2]中国人民解放军陆军第八十集团军医院泌尿外科,山东潍坊261000 [3]潍坊市人民医院神经外五科,山东潍坊261000

出　　处：《中国卫生产业》2023年第24期142-145,共4页China Health Industry

摘　　要：目的探究病案信息管理,着重分析病案首页信息质量控制的作用。方法选取2022年10月—2023年9月中国人民解放军陆军第八十集团军医院10名管理人员为研究对象,2022年10月—2023年3月实施常规病案管理(对照组),2023年4—9月实施病案首页信息质量控制(观察组),实施前后为同一批管理人员。比较分析两组病案首页不合格发生率、病案首页填写质量反馈率、病案首页填写质量评分。结果观察组病案首页不合格发生率、病案首页填写质量反馈率、病案首页填写质量评分均优于对照组,差异有统计学意义(P均<0.05)。结论病案信息管理期间实施病案首页信息质量控制,可减少病案首页不合格、病案首页填写质量反馈现象,可提高病案首页填写质量,应用价值显著。Objective To explore the management of medical records information,and focus on the function of information quality control on the first page of medical records.Methods 10 managers of the 80th Group Military Hospital of the Chinese People's Liberation Army from October 2022 to September 2023 were selected as the study subjects.Regular medical records management(control group)was implemented from October 2022 to March 2023,and information quality control on the first page of medical records was implemented from April to September 2023(observation group).The same group of managers were used before and after management.The incidence of unqualified first page of medical records,the quality feedback rate of filling in the first page of medical records and the quality score of filling in the first page of medical records were compared and analyzed.Results The incidence of unqualified first page of medical records,the feedback rate of filling quality of first page of medical records and the score of filling quality of first page of medical records in the observation group were better than those in the control group,and the differences were statistically significant(all P<0.05).Conclusion During the period of medical records information management,the implementation of information quality control on the first page of medical records can reduce the phenomenon of unqualified first page of medical records and feedback on the quality of filling in the first page of medical records,and can improve the quality of filling in the first page of medical records.

关 键 词：病案信息管理 病案首页信息质量控制 病案首页不合格发生率 病案首页填写质量评分 

分 类 号：R19[医药卫生—卫生事业管理]