摘要
目的分析住院病案首页在院内三方监督评价前后质量差异及变化,为进一步探索院内三方评价在住院病案首页质量持续改进中的应用价值提供参考依据。方法依据住院病案首页数据填写规范(2016版),采用院内三方监督评价模式每月对病案首页质量进行监督评价。将2019年7月1日-12月31日共计48494份住院病案首页,作为实施三方监督评价前期;2020年1月1日-6月30日共计41196份住院病案首页,作为实施后期,随机抽取前期病案2425份与后期病案2060份,分别对比2组住院病案首页平均得分、缺陷评价指标情况。以此评价三方监督评价在病案首页持续质量改进中的应用效果。结果应用院内三方监督评价后住院病案首页平均得分为98.69±0.91分,明显高于实施前96.25±1.92分,差异具有统计学意义。缺陷评价指标中主要诊断选择(编码)错误率、其他诊断错误(漏填)率差异有统计学意义,主要手术操作选择(编码)错误率差异无统计学意义。结论应用院内三方监督评价,可以促使首页数据更加规范、完整、准确。通过完善组织架构、建立奖惩机制、实行绩效考核可以真正实现病案首页内涵质量不断提升。
Objectives To analyze the quality differences and changes of the front page of inpatient medical records before and after the tripartite supervision and evaluation in the hospital,so as to provide reference for further exploring the application value of the tripartite evaluation in the continuous improvement of the front page quality of inpatient medical records.Methods According to the standard for filling in the front page data of inpatient medical records(2016 edition),the quality of the front page of medical records was monitored and evaluated monthly by using the three-party supervision and evaluation mode in the hospital.The period from July 1st,2019 to December 31st,2019 was defined as the early stage of the implementation of tripartite supervision and evaluation,and a total of 48,494 inpatient medical records were front page.The period from January 1st,2020 to June 30th,2020 was defined as the later period of implementation.A total of 41196 inpatient medical records were first page,and the average score and defect evaluation index of the front page of inpatient medical records of the two groups were respectively compared.To evaluate the application effect of tripartite supervision and evaluation in continuous quality improvement of the front page of medical records.Results The average score of the front page of inpatient medical records was 98.69±0.91,which was significantly higher than 96.25±1.92 before the implementation,and the difference was statistically significant.In the defect evaluation index,there were significant differences in the error rate of main diagnosis selection(coding)and other diagnosis errors(missing filling),but there were no significant differences in the error rate of main operation selection(coding).Conclusions The application of tripartite supervision and evaluation in the hospital can make the front page data more standardized,complete and accurate.Through the improvement of organizational structure,the establishment of reward and punishment mechanism,the implementation of performance appraisal,the introduction of talents could truly realize the continuous improvement of the connotation quality of the front page of medical records.
作者
邓娇
郑基华
Deng Jiao;Zheng Jihua(Zigong First People’s Hospital,Zigong 643000,Sichuan Province,China;不详)
出处
《中国病案》
2021年第9期5-7,共3页
Chinese Medical Record
关键词
院内三方监督评价
住院病案首页
持续质量改进
ICD
编码质量
Hospital tripartite supervision and evaluation
Front page of inpatient medical records
Continuous quality improvement
ICD
Coding quality
