摘要
目的通过分析某院现有的住院病案首页修正数据,归纳住院病案首页数据修正的主要原因,探索提升某院住院病案首页数据质量的措施。方法根据国家卫生计生委《住院病案首页数据填写质量规范(暂行)》等文件规定,对某院电子病历系统中记录的2016年1月-6月共6504份住院病案首页修正申请进行统计,并分析其申请原因。结果 2016年一季度住院病案首页修正申请共4058份,修正项目构成中出院时间占14.1%,出院诊断占24.5%,手术信息占10.3%,入院途径占22.3%,病理缺失占5.7%,其他内容占23.1%。在充分调研和数据分析的基础上,二季度某院在管理方式、责任意识、信息化建设三个层面实施了一系列的改进措施。改进后的某院二季度住院病案首页修正申请共2446份,其修正项目构成情况为:出院时间占11.3%,出院诊断占21.7%,手术信息占9.4%,入院途径占26.4%,病理缺失占8.7%,其他内容占22.5%。结论将住院病案首页填写情况进行监控,并针对监控所反映的问题实施相应的改进措施,有助于完善医院住院病案首页管理方式,提高医师填写住院病案首页的责任意识,促进住院病案首页填写的信息化建设,是确保住院病案首页数据质量的有效途径。
Objectives Through studying the modification data of the current existed front pages of medical records,to summarize the primary reasons of the modification,and explore measures to improve the quality of data in the front pages of medical records.Methods According to the rules in the ＂The Fill in Quality Specifications of Front Pages of Inpatient Medical Records（Provisional）＂ and other provisions that announced by the National Health and Family Planning Commission,to conduct statistics on the 6504 copies of modification in the front pages of inpatients medical records from January to June in 2016 through the electronic medical records system of a hospital.Results In the first quarter of 2016,a total of 4058 applications were revised,including 14.1%of discharge time,24.5%of discharge diagnosis,10.3%of surgical information,22.3%of admission,5.7%of Loss of disease detection results,other content accounted for 23.1%.On the basis of investigation and data analysis,a series of improvement measures were carried out in the management,responsibility and information construction in the second quarter.In the second quarter of 2016,a total of 2446 medical applications were revised,including 11.3%of discharge time,21.7%of discharge diagnosis,9.4%of surgical information,26.4%of hospital admissions,8.7%of loss of disease detection results,other content accounted for 22.5%.Conclusions To conduct monitoring on the filling in situation of the front pages of medical records,and carry out corresponding improvement measures according to the problems reflected in the monitoring,which were helpful to improve the management mode,enhance the responsibility of physicians and promote the information construction of the front pages of medical records,and also the effective way to ensure the data quality of the front pages.
作者
肖涟
李迪
孙扬
舒琴
徐小兵
Xiao lian Li Di Sun Yang Shu Qin Xu Xiaobing
出处
《中国病案》
2017年第1期17-20,共4页
Chinese Medical Record
关键词
病案首页
质量
监控
数据
Front pages of medical records
Quality
Monitoring
Data
