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目的了解病案首页填写缺陷情况,分析原因,提出改进措施。方法根据原卫生部《住院病案首页必填项目列表》《住院病案首页数据质量评分标准》《住院病案首页数据质量管理与控制指标》的要求,结合本市实际,制作出《病案首页质量检查评分表》,抽查某市二级及以上医疗机构406份病案首页进行质量检查。结果病案首页填报完整率21.43%,病案首页项目填报完整率94.98%,主要诊断选择正确率83.25%,主要诊断编码正确率50.49%,主要手术及操作选择正确率86.80%,主要手术及操作编码正确率43.42%,其他诊断填写完整正确率86.58%,其他诊断编码正确率43.42%,首页平均分91.17。结论某市病案首页缺陷较多,编码质量参差不齐,现状令人堪忧。各级医院应重视病案首页质量,强化医务人员培训,加强首页质控。病案系统设置必填项及逻辑关联以辅助提高病案首页填写质量。
Objective To understand the first page of medical records to fill in the defects, analyze the reasons and put forward the improvement measures. Methods According to the requirements of the original Ministry of Health “Home Page List of Inpatient Medical Records”, “Home Data Quality Score Standard of Inpatient Medical Records” and “Index Data Quality Control and Control Index of Inpatient Medical Records”, combined with the actual situation of the city, Table ", a random sample of medical institutions in two or more hospitals 406 cases of medical records for quality inspection. Results The complete report rate of the first page of medical record was 21.43%. The complete report rate of the first page of medical record was 94.98%. The correct rate of the main diagnosis was 83.25%. The accuracy of the main diagnostic code was 50.49%. The accuracy of main operation and operation was 86.80% Rate of 43.42%, other diagnosis complete correct rate of 86.58%, other diagnostic coding accuracy rate of 43.42%, home page average score of 91.17. Conclusion There are many defects in the first page of a city’s medical record, the coding quality is uneven and the current situation is worrisome. Hospitals at all levels should pay attention to the quality of the first page of medical records, strengthen the training of medical personnel and strengthen the quality control of the first page. The medical record system sets the required items and the logical correlation to help improve the quality of the medical record homepage.