病案首页全流程质控体系构建及应用  

Construction and application of a full process quality control system for first pages of medical records

作　　者：刘路明 李盈[1] 金雯[1] 殷希[1] LIU Luming;LI Ying;JIN Wen;YIN Xi(The First Affiliated Hospital,College of Medicine,Zhejiang University,Hangzhou 310003,China)

机构地区：[1]浙江大学医学院附属第一医院,浙江杭州310003

出　　处：《现代医院》2024年第11期1722-1725,共4页Modern Hospitals

摘　　要：目的通过实施基于过程管理的全院病案首页全流程质控体系实践评估病案首页内涵质量控制成效。方法某三级医院2020年起开展病案首页质量提升行动,为评估实施效果,定期对病案首页进行随机抽取,依据《住院病案首页数据填写规范(2016版)》进行质量审核,利用数据处理软件,监测质控实施后住院病案首页数据质量控制指标变化及错误构成情况。结果实施病案首页质量控制措施后,医院住院病案首页数据质量指标达到院内目标值,错误类型构成比逐年向好,指标数据逐年提高,差异具有统计学意义。结论构建病案首页全流程质控体系能有效提高住院病案首页内涵质量。Objective To construct a full process quality control system for first pages of medical records based on process management and assess the assess the effectiveness.Methods A tertiary hospital has been conducting quality improvement actions on the quality control of first pages of the medical records since 2020.To assess the effectiveness,the first pages of the medical records were randomly selected regularly,and the quality of first page writing was examined based on the“Specification for Filling in the Face Sheet of the Inpatient Medical Record Data(2016 edition)”.Subsequently,data processing software was used to monitor the changes in the quality control indicators and the categories of error types.Results Following the implementation of the quality control,the quality of data in the first pages met the standards proposed by the hospital.There was a significant,year-over-year improvement in quality control indicators and a favorable trend in the composition of error types,with statistically significant differences.Conclusion The full process quality control system for first pages of medical records established by the hospital can effectively enhance the connotative quality of the first pages of medical records.

关 键 词：住院病案首页 内涵质量 病案质量指标 全流程质控体系 

分 类 号：R197.323.1[医药卫生—卫生事业管理]