摘要
目的通过调查某市二级以上医院住院病案首页填报现状,分析影响病案首页数据质量的原因,提出干预措施。方法依据国家卫生计生委《住院病案首页数据填写质量规范(暂行)》等文件规定,对某市2016年9月1日—2017年2月28日共750份住院病案首页进行质量评价分析。结果全市三级医院7家,二级医院18家,共抽查750份病案,存在缺陷405份,缺陷率54%。病案首页存在问题个数943个,平均问题个数为2.33个,其中三级医院病案首页平均问题个数1.76个,二级医院病案首页平均问题个数为2.36个。结论某市二级以上医院病案首页数据质量欠佳,各级医院应高度重视住院病案首页的填写,加强相关人员的专项培训,管理与临床多部门协作联动以及完善医院信息系统建设,从而达到提高病案首页数据质量的目的。
Objective To investigate the current situation of medical records in a two or three grade hospital in a city and analyze the reasons for affecting the quality of the data of the first page of medical records, and put forward some interventions. Methods According to the provisions of the National Health Planning Commission, ＂filling out the quality specification（temporary） data in the front page of inpatient medical records＂, a total of 750 inpatient medical records in September 2016 and February 2017 were analyzed and evaluated. Results There were 7 hospitals in grade three and two hospitals in grade 18. A total of 750 medical records were selected, 405 defects, and the defect rate was 54%. There are 943 problems in the first page of the medical record, and the average number of questions is 2.33. Among them, the average number of questions in the first page of the three grade hospital is 1.76,and the average number of questions in the first page of the two grade hospital is 2.36. Conclusion The data quality of the first page of medical records in two or three grade hospitals in a city is poor, and hospitals at all levels should attach great importance to filling out the first page of inpatient medical records, and strive to improve the quality of data.
作者
朱锦丽
zhu jinli(Department of Medical Record Management, Affiliated Hospital of Yangzhou University, Yangzhou 225002, Jiangsu Province, Chin)
出处
《中国病案》
2017年第12期10-12,共3页
Chinese Medical Record
关键词
病案首页
数据质量
DRGS
First page of medical records
Data quality
DRGs
