摘要
目的分析中医住院病案首页数据填报缺陷与改进措施。方法将通过国家中医药管理局中医住院病案首页监测与直报系统上报的住院病案首页作为筛查对象,筛选出我院2017年第4季度上报的中医住院病案首页共1 889份,其中有779份曾上传失败,对导致上传失败的原因进行分析(由住院病案首页数据填报缺陷所致),针对这些缺陷制定改进措施干预并应用于我院2018年第4季度工作中,对我院2018年第4季度的住院病案首页数据填报情况进行统计,共收集2013份,统计上传失败的病案数,并分析住院病案首页数据填报缺陷所致的原因,对比干预前后病案首页的数据以及编码情况。结果干预后与干预前相比,患者基本信息漏填错误、主病诊断缺失或编码错误、其它症状诊断缺失或编码错误、主症治疗选择或编码错误、其它症状治疗选择或编码错误所占百分比较低,差异具有统计学意义(P<0.05)。结论通过对我院以往中医住院病案首页数据的分析,发现导致上传失败的原因主要由数据填报缺陷所致,总结其中存在的缺陷包括了患者基本信息漏填错误、主病诊断缺失或编码错误、其它症状诊断缺失或编码错误、主症治疗选择或编码错误、其它症状治疗选择或编码错误,根据这些缺陷制定有利的解决措施,在根本上提高病案首页数据填报以及编码的质量。
Objective To analyze the defects and improvement measures in the homepage data of inpatient medical records of traditional Chinese medicine.Methods Through the homepage of the inpatient medical records reported by the Home Monitoring and Direct Reporting System of the Chinese Medicine Administration of Chinese Medicine,a total of 1 889 home pages of inpatient medical records of TCM reported in the fourth quarter of 2017 were screened out,of which 779 had failed to upload,the reasons for the failure of the upload (due to the defect in the inpatient medical record home data) was analyzed,the development of improvement measures for these defects and application to our hospital in the fourth quarter of 2018.The statistics of the homepage data of the inpatient medical records were collected.A total of 2 013 cases were collected,and the number of medical records failed to be uploaded was counted.The causes of the defects in the inpatient medical records were analyzed.The data and coding status of the medical records before and after the intervention were compared.Results Percentage of patients with missing or missing basic information,missing or coding errors in the main disease,missing or miscoding of other symptoms,treatment options or coding errors,other symptom treatment options,or coding errors Lower,the difference was statistically significant (P < 0.05).Conclusion Through the analysis of the data of the homepage of the previous Chinese medicine inpatients in our hospital,it is found that the cause of the upload failure is mainly caused by the defect of the data,and the defects included in the patient include the missing information of the basic information of the patient,the missing diagnosis of the main disease or the coding error.Other symptoms are missing or coding errors,major treatment options or coding errors,other symptom treatment options or coding errors,and based on these deficiencies,a favorable solution is developed to fundamentally improve the quality of the data on the first page of the case and the quality of the code.
作者
戴保玲
姚常伟
郭静
DAI Baoling;YAO Changwei;GUO Jing(Department of Medical Affairs,Liaocheng Hospital of Traditional Chinese Medicine,Liaocheng Shandong 252000,China;Department of Quality Control,Liaocheng Hospital of Traditional Chinese Medicine,Liaocheng Shandong 252000,China)
出处
《中国卫生标准管理》
2019年第7期11-13,共3页
China Health Standard Management
关键词
中医
住院病案
数据
缺陷
统计
改进措施
Chinese medicine
inpatient records
data
defects
statistics
improvement measures
