住院病案首页主要诊断填写质量监控的实施效果评价  

Implementation Effect Evaluation of the Filling Quality Monitoring of the Main Diagnosis in the Front Page of Inpatient Medical Records

作　　者：郑帼娟 张丽萍 刘海华 Zheng Guojuan;Zhang Liping;Liu Haihua(Department of Medical Records,Longyan Hospital of Traditional Chinese Medicine,Longyan 364000.Fujian Province,China;不详)

机构地区：[1]龙岩市中医院,福建省龙岩市364000

出　　处：《中国病案》2025年第2期10-12,共3页Chinese Medical Record

摘　　要：目的 评价实施住院病案首页主要诊断填写质量监控前后的效果,分析提高住院病案首页主要诊断填写质量的有效途径。方法 选取某三甲中医医院2023年1月1日-2023年12月31日出院病案共18499份,统计2023年1月1日-6月30住院病案首页主要诊断填写缺陷,分析缺陷原因,制定并落实住院病案首页主要诊断填写质量监控的改进措施,与2023年7月1日-12月31住院病案首页主要填写缺陷率比较,使用SPSS 21.0统计软件对两组住院病案首页主要诊断填写缺陷率进行分析,评价实施效果。结果 主要诊断填写缺陷分布科室以外科、骨伤科、康复科为主。填写缺陷分类中以主要诊断选择过于笼统、主要诊断与主要手术操作不对应、未合并编码的缺陷多见。通过实施住院病案首页主要诊断填写质量监控,主要诊断填写缺陷率由11.38%下降到5.10%,各类缺陷发生率两组比较,采用χ^(2)检验,P<0.001。结论 实施住院病案首页主要诊断填写质量监控可显著降低主要诊断填写的缺陷率,提高住院病案首页填写质量。Objectives To evaluate the effect before and after monitoring the quality of main diagnosis filling in the front page of inpatient medical records,and summarize and analyze the effective ways to improve the quality of main diagnosis filling in the front page of inpatient medical records.Methods A total of 18,499 hospital medical records from January 1st,2023 to December 31st,2023 were selected from a Three A and Tertiary TCM Hospital.The main defects of diagnosis filling in the front page of inpatient medical records from January 1 st to June 30th in 2023 were analyzed,and the causes of defects were analyzed.Improvement measures for quality control of main diagnosis filling in the front page of inpatient medical records were developed and implemented.Compared with the defect rate in the front page of inpatient medical records from July 1st to December 31st,2023,SPSS 21.0 statistical software was used to analyze the defect rate in the front page of inpatient medical records and evaluate the implementation effect.Results The main diagnosis and defect distribution departments were surgery,orthopedics and rehabilitation.In the classification of defects,the selection of main diagnosis was too general,the main diagnosis did not correspond to the main operation,and the defects were not combined when the code could be combined.By monitoring the quality of main diagnosis filling in the front page of inpatient medical records,the defect rate of main diagnosis filling decreased from 11.38%to 5.10%.The incidence of various defects was compared between the two groups by x^(2) test(P<0.001).Conclusions Monitoring the quality of main diagnosis filling in the front page of inpatient medical records could significantly reduce the defect rate of main diagnosis filling and improve the quality of filling in the front page of inpatient medical records.

关 键 词：住院病案首页 主要诊断 质量监控 效果评价 

分 类 号：R197.323[医药卫生—卫生事业管理]