逻辑校验和编码质控审核对中医住院病案首页质量的影响  

The Impact of Logical Check and Coding Quality Control Review on the Quality of Filling in the First Page of Inpatient Medical Records in Traditional Chinese Medicine

作　　者：王明飞 李桂凤 粱杨 夏欣 秦林芳 吴文健 WANG Mingfei;LI Guifeng;LIANG Yang;XIA Xin;QIN Linfang;WU Wenjian(Quality Control Department,Guilin Hospital of Chinese Traditional and Western Medicine,Guilin,Guangxi,541004;Medical Records Department,The Affiliated Hospital of Xuzhou Medical University,Xuzhou,Jiangsu,221006)

机构地区：[1]广西桂林市中西医结合医院质控科,广西桂林541004 [2]徐州医科大学附属医院病案统计科,江苏徐州221006

出　　处：《江苏卫生事业管理》2024年第8期1121-1125,共5页Jiangsu Health System Management

基　　金：广西中医药管理局自筹经费科研课题(GXZYC20220511);江苏省医院协会医院管理创新研究课题(JSYGY-2-2023-317)

摘　　要：目的:分析逻辑校验规则和编码质控审核对中医住院病案首页填写质量的影响,为提高中医病案首页质量提供参考。方法:以某中西医结合医院2022年全年21779份住院病案首页为对照组,2023年全年24574份住院病案首页为观察组,根据中医病案首页要求设置逻辑校验,同时对分类编码进行质控,比较分析两组的差异。结果:对照组21779例病案中,缺陷病案3738例;观察组24574例病案中,缺陷病案1818例,经过逻辑校验后,病案首页缺陷率由17.16%降低至7.40%,经卡方检验,缺陷情况具有显著差异(P<0.001),系统逻辑校验效果显著。结论:采用前置逻辑校验程序校验住院病案首页的内容,可以有效地提高病案首页填写的准确性和完整性,有效减少人力成本,提升工作效率,对提高医疗数据质量有积极的影响。Objective:Analyze the impact of logical validation rules and coding quality control audits on the quality of filling in the first page of inpatient medical records in traditional Chinese medicine,providing a reference for improving the quality of the first page of traditional Chinese medical records.Methods:Using 21,779 inpatient medical records from a certain integrated hinese-Western medicine hospital in 2022 as the control group,and 24,574 inpatient medical records from 2023 as the observation group,set up logi⁃cal validation based on the requirements of the first page of traditional Chinese medical records,and conduct quality control on coding,comparing and analyzing the differences between the two groups.Results:The control group had a total of 21,779 medical records,with 3,738 cases of defects;the observation group had a total of 24,574 medical records,with 1,818 cases of defects.After logical vali⁃dation,the defect rate of the inpatient medical record first page decreased from 17.16%to 7.40%.According to the chi-square test,P<0.001,indicating a significant difference in the defect situation,and the systematic logical validation had a significant effect.Conclusion:Using a pre-logic verification program to verify the content of the inpatient medical record first page can effectively improve the accuracy and completeness of filling in the medical record first page,reduce labor costs,improve work efficiency,and have a positive impact on improving the quality of medical data.

关 键 词：逻辑校验 中医病案首页 质量控制 

分 类 号：R197.39[医药卫生—卫生事业管理]