| 黎凤英,黄海葵,闫宁,等.住院病案首页质量管理中的问题及改进措施分析[J].中国临床保健杂志,2023,26(3):352-354. |
| 住院病案首页质量管理中的问题及改进措施分析 |
| Analysis of problems and improvement measures in the quality management of the first page of inpatient medical records based on DRGs |
| 投稿时间：2023-02-15 |
| DOI：10.3969/J.issn.1672-6790.2023.03.014 |
| 中文关键词: 病案 表格和记录管理 质量控制 质量改进 |
| 英文关键词: Medical records Forms and records control Quality control Quality improvement 〖FL |
| 基金项目: |
| 作者 | 单位 | E-mail | | 黎凤英 | 东莞市人民医院,病案科,东莞 523059 | 479518389@qq.com | | 黄海葵 | 东莞市人民医院,病案科,东莞 523059 | | | 闫宁 | 东莞市人民医院,病案科,东莞 523059 | | | 温庆辉 | 东莞市人民医院,检验科,东莞 523059 | | | 何玉燕 | 东莞市人民医院,病案科,东莞 523059 | | | 李锦秀 | 东莞市人民医院,病案科,东莞 523059 | | | 胡甜 | 东莞市人民医院,病案科,东莞 523059 | |
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| 中文摘要: |
| 目的 探讨住院病案首页质量管理存在的问题及改进措施。方法 收集2021年1—6月东莞市人民医院住院病案首页质控措施实施前的500份住院病历作为对照组,同时收集2021年7—12月住院病案首页质控措施实施后的500份住院病历作为研究组。比较住院病案首页质控管理工作实施前后住院病案质量改进情况。结果 研究组病案中甲级病案占比明显高于对照组(P<0.05),乙级病案和丙级病案占比低于对照组(P<0.05)。研究组病案中患者基本信息、住院过程、费用及诊疗信息等缺项数少于对照组(P<0.05),病案首页主要诊断填写、主要手术操作填写、主要诊断编码、主要手术操作编码等正确率高于对照组(P<0.05),病案首页其他诊断填写、其他手术操作填写、其他诊断编码、其他手术操作编码等正确率高于对照组(P<0.05)。研究组病案提交时间及病案归档时间明显短于对照组(P<0.05)。结论 基于疾病诊断相关分组背景下采取住院病案首页质量控制管理有助于提升病案首页准确性和完整性,进而提高病案质量。 |
| 英文摘要: |
| Objective To explore the problems and improvement measures of the first page quality management of inpatient medical records based on the background of disease diagnosis related groups (Diagnosis related groups,DRGs).Methods Collect 500 inpatient medical records before the implementation of quality control measures on the first page of inpatient medical records under the DRGs system from January to June 2021 as the control group,and 500 inpatient medical records after the implementation of quality control measures on the first page of inpatient medical records under the DRGs system from July to December 2021 as the research group.Compare the quality change of inpatient medical records before and after the implementation of quality control management on the first page of inpatient medical records.Results The proportion of Grade A medical records in the study group was significantly higher than that in the control group (P<0.05),and the proportion of Grade B medical records and Grade C medical records in the study group was significantly lower than that in the control group (P<0.05).The number of missing items in the medical records of patients in the study group,such as basic information of patients,hospitalization process information,cost information and diagnosis and treatment information,was significantly lower than that in the control group (P<0.05).The correct rate of main diagnosis,main surgical operation,main diagnostic code and main surgical operation code on the first page of the medical record in the study group was significantly higher than that in the control group (P<0.05).The accuracy rate of other diagnoses,other surgical procedures,other diagnostic codes and other surgical procedures on the first page of the medical record in the study group was significantly higher than that in the control group (P<0.05).The submission time and filing time of medical records in the study group were significantly shorter than those in the control group (P<0.05).Conclusions The quality control management of the first page of inpatient medical records based on the DRGs background is helpful to improve the accuracy and integrity of the first page of medical records,thereby improving the quality of medical records. |
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