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目的分析某院HQMS病案信息上报数据存在的问题,探寻改进措施以提高上报数据质量。方法对某三甲综合医院HQMS近期上报的数据及问题进行统计分析。结果 HQMS月报数据显示住院重返、患者安全、治疗质量等方面的数据出现异常,发生压疮的出院患者例数、发生新生儿产伤例数、发生输血反应的出院患者例数与实际情况不符;另外HQMS上报数据的日报错误信息中89%的为疾病编码错误。结论 HQMS系统功能还需不断完善,信息提取时应给予相应判断功能,减少逻辑错误的发生;同时医院应采取有效措施,加强病案质量管理、病案回收管理和疾病字典库管理,保证病案信息的及时、完整、准确、真实上报。
Objective To analyze the existing problems of HQMS record information reporting data in a hospital and to explore the improvement measures to improve the quality of reported data. Methods The data and problems reported by HQMS in a tertiary general hospital recently were statistically analyzed. Results The monthly data of HQMS showed that there was abnormal data such as hospital visit, patient safety and quality of treatment, the number of discharged patients with pressure ulcers, the number of neonatal births, the number of discharged patients with transfusion reactions and the actual situation Does not match; In addition, HQMS report data daily error message 89% of the disease coding error. Conclusion The function of HQMS system needs to be further improved. Information extraction should be given the appropriate judging function to reduce the occurrence of logic errors. At the same time, hospitals should take effective measures to strengthen the management of medical record quality, medical record recovery management and disease dictionary database to ensure timely medical record information , Complete, accurate, true report.