摘要
目的分析某院病案首页HQMS数据上传现状,提高HQMS网络上报数据质量。方法抽取某院2015年1月1日-2017年12月31日3年上传的HMQS病案首页数据,回顾性分析HQMS上传情况及病案首页填写质量。结果 HQMS病案首页上传主要存在上传缺漏、上传错误等问题,其中上传缺漏情况较严重,2015年出院病案共92473份,缺漏率10. 83%,2016年出院C共96 501份,缺漏率9. 29%,2017年共出院103 147份,缺漏率8. 83%,上传数据错误为数据代码错误及逻辑错误,2015年-2017年间上传缺漏情况及上传错误问题均逐年改善。结论 HQMS数据上传系统有待完善,应设定标准的疾病和手术字典库,组织有资质的编码员上岗,加强病案首页填写的规范化管理,提高病案首页质量。
Objectives To analyze the upload status of HQMS data in the front page of a medical record,and improve the quality of HQMS network reporting data.Methods To select the HQMS medical record front pages data in three years from 2015 to 2017 in a hospital.Then reviewed the uploading and filling quality of front pages HQMS.Results There were mainly uploading and missing data and uploading data errors on HQMS front pages uploads.It was serious to upload missing conditions,during 2015 to 2017,upload omissions and upload errors were improving year and year.Conclusions HQMS data upload system still needed improvement,we should set up standard disease and operation dictionary libraries,organize qualified coders to work,strengthen the standardized of front pages filling and improve the quality of the front pages of medical records.
作者
叶华英
涂晓贤
Ye Huaying;Tu Xiaoxian(Department of Medical Records,Union Hospital Affiliated to Fujian Medical University,Fuzhou 350001,China)
出处
《中国病案》
2019年第3期12-14,共3页
Chinese Medical Record
关键词
HQMS
病案首页
质控
首页质量
HQMS
Medical record front pages
Quality control
Quality of front pages
