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目的设计一种新型的病案首页数据质量控制系统,进一步提高病案首页质量。方法将病案首页质控系统嵌入在病案质检系统中,突出病案首页质量的重要性,改造传统工作流程,前移病案首页填写的完整性、逻辑性、规范性三个维度的核查条件,建立医师编码员互动学习环节,实现所有病案首页全方位全程的实时监控,量化评价科室、医师病案首页质量。结果在应用程序前后,各抽样1200份病案首页,核实住院病案首页填报完整率、项目填报完整率、主要诊断选择正确率、主要手术及操作选择正确率、其他诊断填写完整正确率等指标,分别从70.83%、62.67%、79.67%、91.75%、88.75%上升到96.75%、97.50%、91.67%、94.00%、90.17%,应用后质量指标显著提高,差异具有显著性。病案首页完成天数、病案归档天数由5.38天、7.82天,下降到2.58天、3.76天。结论病案首页质量监控系统能够有效提高病案首页的填写质量,提高医务人员病案完成效率,有利于病案首页质量持续改进。
Objective To design a new home page data quality control system for medical records and to further improve the quality of medical record homepage. Methods The quality control system of the first page of medical record was embedded in the system of medical record examination, which highlighted the importance of the quality of the first page of the medical record, the verification conditions of the three dimensions of completeness, logic and standardization Physician coder interactive learning session, to achieve a full range of real-time monitoring of all cases of home page, quantitative evaluation departments, physicians medical record homepage quality. Results Before and after the application, the samples of 1,200 cases were sampled on the first page to verify the completeness of the first page of inpatients’ medical records, the completeness of the project filing, the correctness of the main diagnostic options, the accuracy of the main surgical and operational options, and the accuracy of other diagnoses. From 70.83%, 62.67%, 79.67%, 91.75% and 88.75% to 96.75%, 97.50%, 91.67%, 94.00% and 90.17% respectively. The quality indexes after application were significantly improved with significant differences. The number of days the first page of the medical records was completed and the number of medical records filed decreased from 5.38 days to 7.82 days to 2.58 days and 3.76 days. Conclusion The first page of the medical record quality control system can effectively improve the quality of the first page of the medical record, improve the medical record efficiency of the medical staff, and improve the quality of the first page of the medical record.