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目的为顺利开展DRGs工作,某市通过对三级医院住院病案首页数据质量检查,发现问题以寻求促进病案首页数据完整性和准确性的提高的方法。方法从某市卫生统计直报系统Oracle数据库中抽取2016年1月-2016年6月三级医院病案首页数据,从缺项、误填、填写规范和逻辑错误方面对住院病案首页进行分析,总结归纳出填报过程中存在的问题。结果病案首页存在问题中缺项率最高,达到40.95%;月龄、新生儿出生、入院体重(克)、患者电话存在误填,误填率最高为5.82%;不规范填写情况最高为6.16%。结论三级医院病案首页质量有待提高,需要加强监管和培训,统一病案首页填写标准,完善全市病案首页质控系统和建立及时反馈机制。
The purpose is to successfully carry out the work of DRGs, a city through the first-class hospital inpatient medical records home page data quality inspection, identify problems in order to seek ways to promote data integrity and accuracy of the first page of medical records. Methods From January 2016 to June 2016, from the Oracle database of a city’s health statistics and direct reporting system, the data of the first grade of hospital medical records from January 2016 to June 2016 were extracted. The first page of inpatient medical records was analyzed from the lack of items, errors and omissions, the filling of norms and logical errors. Summarized the problems in the process of filing. Results The number of absences in the first page of the medical record was the highest (40.95%). The age, newborn’s birth weight and body weight (g) were wrongly filled in, and the highest false-call rate was 5.82%. The highest non-standard number was 6.16% . Conclusion The quality of the first page of medical records in tertiary hospitals needs to be improved. It is necessary to strengthen supervision and training, standardize the homepage of unified medical records, improve the quality control system and establish a timely feedback mechanism.