健康体检主检报告评分体系的构建及效果评价  

Construction and performance evaluation of health examination main report scoring system

作　　者：秦迁[1] 陈静锋 丁素英[1] Qin Qian;Chen Jingfeng;Ding Suying(Health Management Center,the First Affiliated Hospital of Zhengzhou University,Henan Institute of Interconnected Intelligent Health Management,Zhengzhou 450052,China)

机构地区：[1]郑州大学第一附属医院健康管理中心,河南省互联智慧健康管理研究院,郑州450052

出　　处：《中华健康管理学杂志》2025年第2期93-98,共6页Chinese Journal of Health Management

基　　金：国家自然科学基金(72101236);河南省医学科技攻关计划联合共建项目(LHGJ20210354);中国博士后科学基金(2022M722900);河南省科技攻关项目(242102311099);郑州市协同创新项目(XTCX2023006);郑州大学第一附属医院护理团队项目(HLKY2023005)。

摘　　要：目的构建健康体检主检报告评分体系,并对其进行效果评价。方法本研究为应用历史对照研究设计,采用等比例随机抽样法,从2023年12月抽取321份主检报告,并对其进行问题梳理与分析,制定2024年主检报告质量控制计划,构建《主检报告质量控制评分表》,依次对结论词、归类、排序、动态对比、疾病解析、健康指导、一致性、完整性、语言文字、时效性、主检医师11项原则进行评估。每项原则均有对应的评分标准,总分为100分,91~100为甲级、61~90为乙级、≤60为丙级,据此对2024年1—6月抽取的1691份主检报告进行分析。此外,依据主检医师类别(内科和亚专科),对抽取的主检报告进行差异性分析。结果与2023年12月相比,2024年6月的甲级报告占比提升111.3%(χ2=133.38,P<0.001),乙级、丙级报告占比分别降低84.7%、97.6%(χ2=61.82、42.36,均P<0.001)。评分原则分析显示:与2023年12月相比,2024年6月主检报告的结论词、疾病解析、健康指导、一致性的错误率分别改善了54.9%、46.7%、62.9%、100.0%(χ2=27.68、13.41、48.34、7.84,均P<0.001)。与2023年12月相比,2024年1—6月内科及亚专科医师主检报告总评分分别提升6.8%、12.6%(t=-6.843、-5.321,均P<0.001)。结论通过《主检报告质量控制评分表》构建的评分体系科学合理、切实可行,能够有效提升健康体检主检报告质量,且具有较强的可操作性。ObjectiveTo construct a scoring system for the main examination report of health examination and evaluate its effect.MethodsA historical control study design was used in this study.By sorting out the problems in 321 main examination reports from December 2023 by equal proportion random sampling method,the quality control plan of main examination report of 2024 was formulated and the"Quality Control Rating Table of Checkup Summary Report"was constructed,which included the principle of conclusion words,classification,sorting,dynamic comparison,disease analysis,health guidance,consistency,completeness,language expression,timeliness and physician.Each principle had its corresponding scoring standard,with a total score of 100 points,91-100 classified as grade A,61-90 classified as grade B,and≤60 classified as grade C.According to the"Quality Control Rating Table of Checkup Summary Report",1691 main examin reports from January to June 2024 were selected for analysis.In addition,the differences of those reports were analyzed according to categories of primary examination physicians in internal medicine and subspecialties.ResultsCompared with December 2023,the proportion of grade A report in June 2024 increased by 111.3%(χ2=133.38,P<0.001),while the proportion of grade B and C reports decreased by 84.7%(χ2=61.82,P<0.001)and 97.6%(χ2=42.36,P<0.001),respectively.In terms of scoring principles,compared with December 2023,the error rates of conclusion words,disease analysis,health guidance and consistency in June 2024 were improved by 54.9%,46.7%,62.9%and 100.0%,respectively(χ2=27.68,13.41,48.34 and 7.84,all P<0.001).Additionally,compared with 2023,the total scores of the checkup summary reports of internal medicine and subspecialties in 2024 were increased by 6.8%(t=-6.843,P<0.001)and 12.6%(t=-5.321,P<0.001),respectively.ConclusionThe scoring system constructed through the"Quality Control Rating Table of Checkup Summary Report"is scientific,reasonable and practical,which can effectively improve the quality of the main

关 键 词：主检报告 健康体检 质量控制 评分体系 效果评价 

分 类 号：R47[医药卫生—护理学]