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目的通过病案首页质控提高医疗统计信息的准确性,为DRGs付费制度奠定基础,为医院的管理和决策提供信息支持。方法建立医院病案首页质量控制体系,制定《病案首页质量控制评分表》,抽取某院实施病案首页质控前后共10 402份病案进行填报质量评分,采用SPSS19.0对比分析质控前后病案首页信息的完整度、错误率、得分情况。结果建立病案首页质控体系后,病案首页填写不完整率降低,差异有统计学意义(χ2=256.28,P<0.001);入院病情填写、门诊诊断、手术及操作日期、麻醉方式、切口愈合等级、手术级别、出生地址、身份证号、新生儿出生体重等错误率均有所下降,差异有统计学意义(P<0.05);病案首页质控评分差异有统计学意义(Z=-20.322,P<0.001)。结论建立病案首页质量控制体系使病案首页填写质量得到有效提升,同时病案首页的质量控制需要多个部门共同协作,持续为病案首页质量把关。
OBJECTIVE To improve the accuracy of medical statistics through the quality control of medical record home page, lay the foundation for DRGs payment system and provide information support for hospital management and decision-making. Methods The first page of the hospital medical record quality control system was established and the “Medical Record Home Quality Control Scoring Table” was drawn up. A total of 10 402 medical records were collected before and after quality control in a hospital for quality control. SPSS 19.0 was used to compare the medical records before and after The integrity, error rate, score situation. Results After the establishment of the quality control system of the first page of the medical record, the incompleteness of the first page of the medical record was reduced with a statistically significant difference (χ2 = 256.28, P <0.001). The admission condition, outpatient diagnosis, operation and operation date, anesthesia, (P <0.05). There was significant difference in quality control index between the first case and the second case (Z = -20.322, P < P <0.001). Conclusion The establishment of the first homepage quality control system for medical records effectively improved the quality of the first page of medical records, and the quality control of the first page of medical records required the cooperation of multiple departments to ensure the quality of the first page of medical records.