病案室编码的病案信息技术对病案质量的影响分析  

Analysis of the Impact of Medical Record Information Technology Encoded in the Medical Record Room on the Quality of Medical Records

作　　者：张欣 张舒祺 陈宇 张启兰 王乐 ZHANG Xin;ZHANG Shuqi;CHEN Yu;ZHANG Qilan;WANG Le(Medical Records Room,Affiliated Hongqi Hospital of Mudanjiang Medical University,Mudanjiang 157011,Heilongjiang,China)

机构地区：[1]牡丹江医科大学附属红旗医院病案室,黑龙江牡丹江157011

出　　处：《中国卫生产业》2024年第24期68-70,74,共4页China Health Industry

摘　　要：目的 探讨基于病案室编码的病案信息技术用于病案质量管理的价值。方法 选取牡丹江医科大学附属红旗医院病案室的6名研究管理人员为研究对象,2019年1月-2021年1月为对照组,实施常规管理模式,选取50 000份病案;2021年3月-2023年3月为观察组,实施病案信息技术,选取50 000份病案;对比两组编码准确性,病案质量和管理满意度评分。结果 观察组编码准确率99.40%(49 700/50 000)比对照组99.20%(49 600/50 000)高,差异有统计学意义(χ^(2)=14.386,P<0.05)。观察组病案质量评分及管理满意度评分均比对照组高,差异有统计学意义(P均<0.05)。结论 在病案信息化建设中,病案信息技术可以有效地提升患者的病案代码和病案的质量,有利于推动病案工作的发展。Objective To explore the value of using medical record information technology based on medical record room coding for medical record quality management.Methods Six research managers of the Medical Record Room of Affiliated Hongqi Hospital of Mudanjiang Medical University were selected as the study subjects.From January 2019 to January 2021,the control group implemented routine management mode and selected 50000 medical cases;from March 2021 to March 2023,the observation group implemented medical record information technology and selected 50000 medical records;Compare the accuracy of coding,quality of medical records manage satisfaction score between two groups.Results The coding accuracy of the observation group 99.40%(49700/50000)was higher than 99.20%(49600/50000)of the control group,and the difference was statistically significant(χ^(2)=14.386,P<0.05).The scores of medical records quality and management satisfaction of the observation group were higher than those of the control group,the differences were statistically significant(all P<0.05).Conclusion In the construction of medical record informatization,medical record information technology can effectively improve the patient's medical record code and quality,which is very helpful for promoting the development of medical record work.

关 键 词：病案信息技术 病案室编码 病案质量 病案管理 

分 类 号：R19[医药卫生—卫生事业管理]