住院病案质控数字化转型的实践与思考  

Practice and Reflection on Digital Transformation of Inpatient Medical Record Quality Control

作　　者：蒋菁 吴松[1] 易石坚[1] 李彬[1] 周平[1] Jiang Jing;Wu Song;Yi Shijian;Li Bin;Zhou Ping(不详;South China Hospital of Shenzhen University,Shenzhen 518100,Guangdong Province,China)

机构地区：[1]深圳大学附属华南医院,广东省深圳市518100

出　　处：《中国病案》2024年第8期3-5,共3页Chinese Medical Record

摘　　要：目的探讨在新建医院实施“住院病案质控数字化转型”的实践效果,提高病案质控效能,提升病案质量。方法通过改造病案质控系统,实施住院病案质控数字化转型,调取实施前2023年4月1日-2023年6月30日5902份系统质控及1823份人工质控的病案质控数据和实施后2023年7月1日-2023年9月30日6830份系统质控及1935份人工质控的病案质控数据,比较两组科级病案质控率、科级病案质控整改率、院级病案质控率、院级病案质控整改率、病案时效性质控项目缺陷率、病案内涵质控项目缺陷率的变化。结果科级病案质控率、科级病案质控整改率由实施前的9.76%、89.93%提高至实施后的16.47%、96.18%,P<0.05,差异具有统计学意义;院级病案质控率由21.13%降至11.86%,院级病案质控整改率由96.87%提高至99.38%,P<0.05,差异具有统计学意义;病案时效性质控项目:全量病历书写时效性、入院记录24小时内完成、手术记录24小时内完成的缺陷率由实施前的15.99%、3.21%、25.60%降至实施后的12.11%、2.55%、22.79%,P<0.05,差异具有统计学意义;病案内涵质控项目:术前讨论记录、术前小结、术后首次病程记录、手术记录、三级查房记录、会诊记录、危急值记录、住院超30天患者病案记录的缺陷率由实施前的15.26%、10.09%、13.50%、7.28%、5.65%、17.55%、9.68%、31.62%降至实施后的9.79%、1.80%、8.21%、4.05%、4.24%、12.43%、2.54%、15.11%,P<0.05,差异具有统计学意义。结论“住院病案质控数字化转型”在提高病案质控效能,提升病案质量上均有明显的促进作用,可为其他医院的病案质量控制提供借鉴和参考。Objectives To explore the practical effects of implementing the digital transformation of inpatient medical record quality control in newly built hospital,so as to improve the efficiency of medical record quality control and the quality of medical records.Methods Through the transformation of the medical record quality control system,the digital transformation of inpatient medical record quality control was implemented.The quality control data from April 1st to June 30th,2023 were taken as the pre-implementation group,including 5902 medical records of system quality control and 1823 medical records of manual quality control.The quality control data from July 1st to September 30th,2023 were taken as the post-implementation group,including 6830 medical records of system quality control and 1935 medical records of manual quality control.The changes of quality control rate of section-level medical records,rectification rate of quality control of section-level medical records,quality control rate of hospital-level medical records,rectification rate of quality control of hospital-level medical records,defect rate of medical record timeliness quality control items,and defect rate of medical record connotation quality control items were compared.Results The quality control rate of section-level medical records and the rectification rate of section-level medical records increased from 9.76%and 89.93%before implementation to 16.47%and 96.18%after implementation,P<0.05,and the difference was statistically significant.The quality control rate of hospital-level medical records decreased from 21.13%to 11.86%,and the rectification rate of quality control of hospital-level medical records increased from 96.87%to 99.38%,P<0.05,the difference was statistically significant.Quality control items of medical record timeliness:the defect rate of full medical records,admission records within 24 hours and surgical records within 24hours decreased from 15.99%,3.21%and 25.60%before implementation to 12.11%,2.55%and 22.79%after implementati

关 键 词：住院病案质控 数字化 可视化 时效性 内涵质控1 

分 类 号：R197.323[医药卫生—卫生事业管理]