病案首页智能化建设分析及质控系统实践应用  

Analysis of intelligent construction and application of intelligent quality control system for inpatient medical record first-page

作　　者：钱露华 王缨 傅颖 QIAN Luhua;WANG Ying;FU Ying(Department of Medical Records Statistics,Changzhou City Cancer Hospital,Changzhou 213000,Jiangsu Province China)

机构地区：[1]常州市肿瘤医院病案统计室,江苏常州213000

出　　处：《中国数字医学》2024年第11期50-55,共6页China Digital Medicine

基　　金：2023年度医院管理创新研究课题(JSYGY-3-2023-96)。

摘　　要：目的:评价某三级公立医院住院病案首页智能化质控系统的应用效果。方法:通过探究病案质量的影响因素,结合972条病案系统校验规则,构建智能化病案质量控制系统,对比分析2023年1月至6月与2023年7月至12月的病案数据,评价系统应用效果。结果:影响病案首页质量的主要因素是逻辑类数据,智能化质控系统显著提升了病案首页数据的准确性、完整性和规范性。结论:智能化质控系统是提升住院病案首页质量的有效工具,为医院管理决策和医疗服务质量提升提供了有力支持。Objective To evaluate the application effect of an intelligent quality control system on first-page of inpatient medical records in a tertiary public hospital.Methods By exploring the factors influencing the quality of medical records,and based on 972 rules of medical record system verification,an intelligent medical record quality control system was constructed.The application effect of the system was evaluated by comparing the medical record data from January to June 2023 with that from July to December 2023.Results The quality of the first-page of medical record was mainly affected by logic data.The intelligent quality control system significantly improved the accuracy,integrity and standardization of the data in the medical record first page.Conclusion The intelligent quality control system is an effective tool to improve the quality of inpatient medical record first page,which can provide strong support for hospital management decision-making and medical service quality improvement.

关 键 词：住院病案首页 智能化质控 数据质量 校验规则 

分 类 号：R197.3[医药卫生—卫生事业管理] R319[医药卫生—公共卫生与预防医学]