住院病案首页质量管理存在的问题及双线双向督查机制 应用实践效果分析  

Problems and application of dual-line bidirectional supervision mechanism in quality management of inpatient medical records

作　　者：殷祥 欧阳达 易松 YIN Xiang;OUYANG Da;YI song(Yichun People’s Hospital,Yichun 336000,China)

机构地区：[1]宜春市人民医院,江西宜春336000

出　　处：《现代医院》2025年第4期545-548,共4页Modern Hospitals

基　　金：江西省卫生健康委科技计划项目(202212663)。

摘　　要：目的探究住院病案首页质量管理存在的问题及分析双线双向督查机制应用实践效果。方法回顾性收集医院2023年1月—2023年6月(未实施双线双向督查机制阶段)的500份住院病案并归纳至对照组,收集2024年1月—2024年6月(实施双线双向督查机制阶段)的500份住院病案并归纳至观察组,探究两组住院病案首页质量管理存在的主要问题及分布情况,比较两组住院病案首页质量管理情况。结果①信息漏填或不全、入院病情选择错误、手术及操作编码错误是两组住院病案首页存在的三大主要问题,但观察组各项质量管理问题占比均低于对照组(P<0.05);②观察组甲级病案率为90.20%(451/500),对照组甲级病案率为85.60%(428/500);③观察组住院病案首页中存在缺陷的基本信息总项目数占比低于对照组(P<0.05);④观察组住院病案首页转科原因、离院方式等住院过程信息缺陷总项目数占比低于对照组(P<0.05);⑤观察组住院病案首页主要诊断名称与顺序、手术及相关操作等诊疗信息缺陷总项目数占比低于对照组(P<0.05);⑥观察组住院病案首页各项费用金额、费用类别等费用信息缺陷总项目数占比低于对照组(P<0.05)。结论住院病案首页质量管理主要存在信息漏填或不全、入院病情选择错误、手术及操作编码错误等问题;住院病案首页接受双线双向督查机制管理,有利于促进住院病案首页信息的完整性与准确性,提高病案管理质量,优化DRG分组效果,实践效果可观,具有推广价值。Objective To explore the problems in quality management of inpatient medical records and analyze the application effect of the dual-line bidirectional supervision mechanism.Methods Retrospective collection of 500 inpatient medical records from January 2023 to June 2023(before the implementation of the dual-line bidirectional supervision mechanism)and classified as the control group.Also,500 inpatient medical records from January 2024 to June 2024(during the implementation of the dual-line bidirectional supervision mechanism)and classified as the observation group.The main problems and distribution of quality management in the two groups were explored and compared.Results①Incomplete or omitted information,incorrect selection of admission condition,and coding errors were the three main problems in the inpatient medical records of the two groups,but the proportion of quality management problems in the observation group was lower than that in the control group(P<0.05).②The proportion of Grade A cases in the observation group was 90.20%(451/500),while the proportion in the control group was 85.60%(428/500).③The proportion of basic information defects in the inpatient medical records of the observation group was lower than that of the control group(P<0.05).④The proportion of defects in the inpatient process information,such as reasons for transfer and discharge methods,in the observation group was lower than that in the control group(P<0.05).⑤The proportion of defects in diagnostic names and order,surgeries and related operations,and other treatment information in the inpatient medical records of the observation group was lower than that of the control group(P<0.05).⑥The proportion of defects in cost information,such as total expenses and expenses categories,in the inpatient medical records of the observation group was lower than that of the control group(P<0.05).Conclusion The main problems in quality management of inpatient medical records include incomplete or omitted information,incorrect selection of a

关 键 词：住院病案 首页质量管理 双线双向督查 

分 类 号：R197.32[医药卫生—卫生事业管理]