摘要
目的分析科技病案质控管理系统在住院病案首页质控中的应用效果。方法选取2022年6—12月福建医科大学附属第一医院的住院病案8568份,通过医院病案质控管理流程进行人工逐一筛查质控,作为对照组;选取2023年6—12月住院病案8754份,通过科技病案质控管理系统进行逻辑校验后,作为观察组。比较两组病案首页患者基本信息、患者住院过程信息、患者住院诊疗信息填写缺陷项目分布的差异。结果对照组共检出缺陷病历3257份,总缺陷率为38.01%(3257/8568),观察组共检出缺陷病历1597份,总缺陷率为18.24%(1597/8754),运用科技病案质控管理系统后,住院病历缺陷率下降,差异有统计学意义(χ^(2)=839.113,P均<0.001)。结论应用科技病案质控管理系统对住院病案首页进行逻辑校验的智能化质控,能有效降低住院病案填写的缺陷率,提高住院病案首页数据质量。
Objective To analyze the application effect of the quality control management system of scientific and technological medical records in the quality control of the first page of inpatient medical records.Methods A total of 8568 inpatient medical records from the First Affiliated Hospital of Fujian Medical University from June 2022 to December were selected as the control group,and the quality control was manually screened one by one through the quality control management process of hospital medical records.A total of 8754 inpatient medical records from June 2023 to December were selected as the observation group after logical verification through the quality control management system of scientific and technological medical records.The differences in the basic information of patients on the front page of medical records,the information of patients'hospitalization process,and the distribution of defective items filled in by patients'hospitalization information were compared between the two groups.Results A total of 3257 defective medical records were detected in the control group,with a total defect rate of 38.01%(3257/8568).A total of 1597 defective medical records were detected in the observation group,with a total defect rate of 18.24%(1597/8754).After using the quality control management system of scientific and technological medical records,the defect rate of inpatient medical records showed a significant downward trend,the difference between the two groups was statistically significant(χ^(2)=839.113,all P<0.001).Conclusion The intelligent quality control of logical verification of the first page of inpatient medical records by applying the quality control management system of scientific and technologi cal medical records can effectively reduce the defect rate of filling in inpatient medical records,improve the data quality of the first page of inpatient medical records,and ensure the accuracy of the big data of performance appraisal in national public hospitals.
作者
陈筱婧
CHEN Xiaojing(Medical Record Room,the First Affiliated Hospital of Fujian Medical University,Fuzhou 350000,Fujian,China;National Regional Medical Center,Binhai District,the First Affiliated Hospital of Fujian Medical University,Fuzhou 350005,Fujian,China)
出处
《中国卫生产业》
2024年第12期156-159,共4页
China Health Industry
基金
福建医科大学附属第一医院院级课题(2022FY-R-07)。
关键词
病案首页
质控系统
病案管理
智能化
Medical record home page
Quality control system
Medical record management
Intelligent
