摘要
目的评价病案首页质控系统在病案首页质量控制中的效果及探讨该系统使用过程中所存在的问题,研究病案首页质控系统提高病案首页质量的对策。方法收集邵阳市中心医院在病案首页质控系统使用前后医院质量监控系统(hospital quality monitoring system, HQMS)网络直报病案首页49 055份和38 287份,分析首次上报不合格的病案首页全部信息和病案首页质控系统使用过程中所存在的问题。结果病案首页质控系统使用前HQMS网络直报病案首页合格率为76.87%;质控系统使用后HQMS网络直报病案首页合格率为99.16%,病案首页合格率较使用前提高了22.29%,其中个人信息合格率提高了3.74%,治疗信息合格率提高了20.43%;提高最多的条目为治疗信息中的病理诊断范围(提高率为12.20%)和诊断编码范围(提高率为4.32%);住院过程信息(提高率为0.05%)和费用信息(提高率为0)提高不明显。质控系统使用过程中出现的主要问题是质控系统校验结果不精确和医生对该系统的很多规则不了解。结论病案首页质控系统能有效提高HQMS网络直报病案首页的合格率,节省人力物力,使用方便,值得推广应用。
Objective To evaluate the effect of the medical record home page quality control system on the medical record home page quality control and the problems eristing in the use of the system and countermeasures to improve the quality of front page of medical records by the quality control system.Methods 49055 and 38287 copies of the first page of medical records were directly reported by HQMS network before and after the use of the quality control system on the first page of medical records in a third-level first-class hospital in Hunan Province,and all the information of the first page of unqualified medical records and the problems existing in the use of the quality control system on the first page of medical records were analyzed.Results Before the use of the quality control system on the first page of medical records,the qualified rate of HQMS network directly reported the first page of medical records was 76.87%.After the use of the quality control system,the qualified rate of the first page of the medical records directly reported by the HQMS network was 99.16%,and the qualified rate of the first page of the medical records increased by 22.29%compared with before,among which the qualified rate of personal information increased by 3.74%,and the qualified rate of treatment information increased by 20.43%.The most improved items were the range of pathological diagnosis in the treatment information(12.20%increased)and the range of diagnostic codes(4.32%increased);Inpatient process information(0.05%increase)and cost information(0 increase)were not significantly improved.The inaccuracy of the calibration result of the quality control system and the doctor’s ignorance of the most rules of the system are the main problems in the process of using the system.Conclusion The quality control system of the first page of the medical record can effectively improve the qualified rate of the first page of the HQMS network direct report and save manpower and material resources,easy to use,which is worthy of popularization and application.
作者
肖峰
张国华
方艳春
XIAO Feng;ZHANG Guohua;FANG Yanchun(School of Public Health,University of South China,Hengyang 421001,China;Department of Spine Surgery,Shaoyang Hospital of Traditional Chinese Medicine,Shaoyang 422000,China;Health Education Office of Shaoyang Central Hospital,Shaoyang 422000,China)
出处
《邵阳学院学报（自然科学版）》
2021年第2期90-94,共5页
Journal of Shaoyang University：Natural Science Edition
关键词
病案首页质控系统
病案首页
质量控制
quality control system of the first page of medical records
first page of medical record
quality control
