摘要
目的探讨提高住院病案首页数据质量的方法。方法依据医院基于DRGs的住院病案首页质量监测系统,导入2016年6月1日-12月31日和2017年6月1日-12月31日首次调取的共计107773份住院病案首页,从病案首页完整性、规范性、一致性、逻辑性校验,汇总统计缺陷和错误次数,评估该系统的监控效果。结果病案首页完整性缺陷同比下降了3.93%,一致性缺陷下降了0.26%,逻辑性缺陷下降了0.54%,仅规范性因该医院疾病诊断库换库缺陷上升了0.04%,两年比较差异具有统计学意义(P<0.05)。结论通过病案首页监测系统,促进某医院的病案首页数据质量在不断提高。
Objective To improve the data quality of the home page of the medical records. Methods To import the first transfer of 107773 patients from June 1 st 2016 to December 1 st 2017 into the system for surveillance of the quality of the front page data of medical records based on DRGs, check from the integrity, standardization, consistency and logic of the front page of medical records, and tabulate statistics defects and errors, evaluate the monitoring effect of the platform. Results The integrity defects of the front page of the medical records fell 3.93% on year-on-year basis, the conformance defect dropped by 0.26%, the logical defects dropped by 0.54%, only normative defects increased by 0.04% due to disease diagnosis repository defects, the two years of comparison were statistically significant（P〈0.05）. Conclusions Through the quality monitoring system, the data quality of the front page of medical records in the hospital was improving constantly.
作者
田伟
尹桂华
初爱娟
王宪秀
董新娇
Tian Wei;Yin Guihua;Chu Aijuan;Wang Xianxiu;Dong Xinjiao(Central Hospital of Linyi,Linyi 276400,China)
出处
《中国病案》
2018年第10期9-11,共3页
Chinese Medical Record
基金
山东省医药卫生科技发展计划项目(2017WS784)
关键词
住院病案首页
数据质量
监测系统
效果评价
疾病诊断相关分组
Front page of medical records
Data quality
System for surveillance
Effect assessment
Diagnosisrelated groups
