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目的探讨校验功能及绩效考核对病案统计质量的影响。方法 2014年1月实行病案首页的校验功能,2014年4月实行病案首页的绩效考核,故随机抽取2013年10月-2013年12月及2014年4月-2014年6月的电子病案首页各3600份,统计基本信息、医疗信息、住院费用信息、电子签名等的缺陷率,数据使用SPSS17.0软件统计,采用χ2检验。结果 2014年4月-2014年6月与2013年10月-2013年12月比较,患者基本信息、医疗信息、住院费用信息、电子签名缺陷率均下降,两时间段差异有统计学意义(P<0.05);结论校验功能与绩效考核使病案统计质量不断提高。
Objective To explore the impact of verification function and performance appraisal on the quality of medical record statistics. Methods The first page of medical records was verified in January 2014 and the first page of medical records in April 2014. Therefore, the e-medical records of October 2013-December 2013 and April 2014-June 2014 were selected randomly The 3600 copies of the basic statistical information, medical information, hospitalization costs, electronic signatures and other defects, the data using SPSS17.0 software statistics using χ2 test. Results From April 2014 to June 2014, compared with October 2013-December 2013, the basic information, medical information, hospitalization expenses information and defect rate of electronic signature decreased, with significant difference between two periods (P <0.05). Conclusion The verification function and performance appraisal have continuously improved the quality of medical record statistics.