公立医院绩效考核视角下住院病案首页事后质控分析  

Post Quality Control Analysis on the Front Page of Medical Records from the Perspective of Performance Appraisalof Public Hospitals

作　　者：石函宁 宋慧[1] 吴文靖[1] 吴红星[1] 赵曼 周静[1] Shi Hanning;Song Hui;Wu Wenjing;Wu Hongxing;Zhao Man;Zhou Jing(Jiangsu Subei People's Hospital,Yangzhou 225001,Jiangsu Province,China;不详)

机构地区：[1]江苏省苏北人民医院,江苏省扬州市225001

出　　处：《中国病案》2024年第6期12-14,共3页Chinese Medical Record

基　　金：扬州市政策引导计划(软科学研究)项目(YZ2022224)。

摘　　要：目的 建立住院病案首页字段质控规则,通过事后质控,提高住院病案首页质量和上传效率。方法 根据全国三级公立医院绩效考核与医疗质量管理住院病案首页采集系统接口标准,对811个住院病案首页字段建立49条质控规则,通过使用Python软件构建事后质控管理框架,2022年6月1日-2023年6月30日对158 513份住院病案首页进行质控,每月15日前对上1个月度的住院病案首页进行全量质控,质控结果及时反馈病案信息小组进行整改。结果 平均每月质控住院病案首页12 193份,月度住院病案首页问题反馈次数从12次下降到4次,报错率从35.9%下降到16.3%。报错主要集中在病案编码员失误、信息系统故障、未发现的潜在问题等突发情况。结论 月度事后质控,可以较好地提升住院病案首页质量,提升绩效考核平台住院病案首页数据上传的准确性。Objectives To establish the quality control rules of the front page field of inpatient medical records,and improve the quality and uploading efficiency of the front page of inpatient medical records through the post quality control.Methods According to the interface standard of performance appraisal and medical quality management inpatient medical record first page collection system of national tertiary public hospitals,49 quality control rules were established for 811 inpatient medical record first page fields,and a post-event quality control management framework was constructed by using Python software.From June 1,2022 to June 30,2023,quality control was carried out on the first page of 158513 inpatient medical records,and full quality control was carried out on the first page of inpatient medical records of the previous month before the 15th of each month,and the quality control results were timely reported to the medical records information team for rectification.Results There were an average of 12193 quality control inpatient medical records on the first page per month.The number of problems feedback on the first page of inpatient medical records decreased from 12 to 4,and the error rate decreased from 35.9%to 16.3%.Errors are mainly reported in emergency cases such as errors of medical record coders,information system failures,and undiscovered potential problems.Conclusion Monthly post quality control can improve the quality of the first page of inpatient medical records and improve the accuracy of data uploading on the first page of inpatient medical records on the performance assessment platform.

关 键 词：住院病案首页 绩效考核 事后质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]