住院病案首页专项质控的应用价值分析  

Analysis on the Application Value of Special Quality Control on the First Page of Inpatient Medical Records

作　　者：胡晓娟 边纯梅 张红艳 HU Xiaojuan;BIAN Chunmei;ZHANG Hongyan(Medical Record Room,Zibo Maternal and Child Health Hospital,Zibo,Shandong Province,255000 China;Medi-cal Record Room,Zibo Central Hospital,Zibo,Shandong Province,255000 China)

机构地区：[1]淄博市妇幼保健院病案室,山东淄博255000 [2]淄博市中心医院病案室,山东淄博255000

出　　处：《中国卫生产业》2024年第2期58-61,共4页China Health Industry

摘　　要：目的探讨住院病案首页专项质控的应用价值。方法选取2022年5月—2023年5月淄博市妇幼保健院住院完整病历资料2000例以及同期病案室工作人员20名为研究对象。按照病案首页质控方式不同分组,观察组实施住院病案首页基本信息专项质控管理,对照组针对病案首页基本信息实施常规管理。比较两组病案首页质控得分、病案首页常见错误来源、病案首页填写耗时和病案归档时首页填写完整率。并对两组工作人员整体工作效率评价得分进行比较。结果观察组内科系统、外科系统、妇产科系统及儿科系统病案首页质控得分均高于对照组,差异有统计学意义(P均<0.05);观察组病案首页常见错误中,抢救情况漏填率,地址邮编漏填率,手术、操作漏填率,离院方式错误率均低于对照组,观察组病案首页填写耗时短于对照组,病案归档时首页填写完整率高于对照组差异有统计学意义(P均<0.05)。观察组工作人员整体工作效率评价得分高于对照组,差异有统计学意义(P<0.05)。结论针对住院病案首页基本信息进行专项质控,可显著提高病案首页质控得分,减少漏填、错填比例,提高填写效率,确保首页填写完整率,提高病案管理人员工作效率。Objective To explore the application value of special quality control on the first page of inpatient medical records.Methods A total of 2,000 complete medical records of patients hospitalized in Zibo Maternal and Child Health Hospital from May 2022 to May 2023 and 20 staff of the medical record room during the same period were selected as the research and analysis objects.They were divided according to the quality control method of the first page of inpatient medical records.The observation group implemented special quality control management of the basic information on the first page of the inpatient medical records in this study,while the control group implemented routine management of the basic information on the first page of the medical records.Compare the quality control scores of the first pages of the two groups of medical records,the common sources of errors on the first pages of medical records,and the time taken to fill in the first pages of medical records and the completion rate of filling in the first pages when archiving the medical records.And compare the overall work efficiency evaluation scores of the two groups of staff.Results The quality control scores of the medical record home page of the internal medicine system,surgical system,obstetrics and gynecology system and pediatric system in the observation group were all higher than those in the control group,and the difference was statistically significant(P<0.05).Among the common errors on the first page of the medical records in the observation group,the error rate of missing rescue information,missing address and postal code,missing surgery and operations,and incorrect filling in the method of discharge from the hospital were all lower than those in the control group,and the observation group took less time to fill in the first page of the medical records than the control group,and the completion rate of filling in the first page of the medical records when filing was higher than the control group,the differences were statistically significan

关 键 词：住院病案 病案首页 基本信息 专项质控 

分 类 号：R197[医药卫生—卫生事业管理]