【摘要】：住院病案首頁(yè)信息是患者在醫(yī)院住院醫(yī)療過(guò)程中全部信息的濃縮精華,目前住院病案首頁(yè)信息經(jīng)常存在缺項(xiàng)、漏項(xiàng)、填寫(xiě)錯(cuò)誤等質(zhì)量問(wèn)題。為了提高信息質(zhì)量,本文對(duì)某醫(yī)院2015年上半年的住院病案首頁(yè)信息質(zhì)量現(xiàn)狀進(jìn)行了評(píng)價(jià)、對(duì)醫(yī)院內(nèi)全部住院醫(yī)師進(jìn)行了問(wèn)卷調(diào)查、對(duì)病案管理委員會(huì)成員進(jìn)行了專家訪談以及組成品管圈小組。利用描述性統(tǒng)計(jì)分析、根因分析、非條件Logistic回歸分析等方法,分析了住院病案首頁(yè)信息質(zhì)量的影響因素,制定并實(shí)施了干預(yù)對(duì)策,在干預(yù)對(duì)策實(shí)施6個(gè)月后,對(duì)2016年上半年與2015年上半年的住院病案首頁(yè)信息質(zhì)量進(jìn)行了對(duì)比分析。研究結(jié)果表明:(1)住院病案首頁(yè)信息質(zhì)量的主要影響因素包括對(duì)首頁(yè)質(zhì)量重視度不夠、培訓(xùn)次數(shù)少、病歷系統(tǒng)不完善、自查率低、獎(jiǎng)勵(lì)力度小;(2)干預(yù)對(duì)策實(shí)施6個(gè)月后,住院醫(yī)師填寫(xiě)住院病案首頁(yè)信息不合格率由2015年上半年的29.32%顯著下降到2016年上半年的10.14%(χ2=1741.65,P0.01)。病案編碼員對(duì)疾病和手術(shù)操作編碼不合格率由2015年上半年的9.39%下降到2016年上半年的5.57%(χ2=157.10,P0.01)。(3)有效干預(yù)對(duì)策包括加強(qiáng)醫(yī)院管理人員與醫(yī)務(wù)人員對(duì)住院病案首頁(yè)信息質(zhì)量重要性的認(rèn)識(shí);加強(qiáng)住院病案首頁(yè)信息填寫(xiě)規(guī)則的學(xué)習(xí)、培訓(xùn);優(yōu)化電子病歷系統(tǒng)中住院病案首頁(yè)的信息平臺(tái)服務(wù);執(zhí)行和完善醫(yī)院對(duì)住院病案首頁(yè)信息質(zhì)量的相關(guān)考核制度;完善和優(yōu)化醫(yī)院對(duì)住院病案首頁(yè)信息質(zhì)量的獎(jiǎng)懲機(jī)制等。
[Abstract]:The first page information of the medical record is the essence of all the information of the patient in the course of hospital medical treatment. At present, there are many quality problems in the front page of the medical record of the hospital, such as missing items, filling out mistakes, and so on. In order to improve the quality of information, this paper evaluates the present situation of the first page of a hospital's medical record in the first half of 2015, and makes a questionnaire survey on all resident physicians in the hospital. The members of the Medical record Management Committee were interviewed by experts and formed a quality control group. By means of descriptive statistical analysis, root cause analysis, non-conditional logistic regression analysis, this paper analyzed the factors affecting the information quality of the first page of the medical record, formulated and implemented the intervention countermeasures, and implemented the intervention countermeasures 6 months after the implementation of the intervention measures. The information quality of the first half of 2016 and the first half of 2015 was compared. The results show that: (1) the main influencing factors of the information quality of the first page of the medical record include insufficient attention to the quality of the first page, less training, imperfect medical record system, low self-examination rate and small incentive; (2) six months after the implementation of the intervention countermeasures, The rate of failing to fill out the first page of the medical record of the resident decreased significantly from 29.32% in the first half of 2015 to 10.14% in the first half of 2016 (蠂 ~ 2 / 1741.65p ~ (0.01). The unqualified rate of disease and operation codes was reduced from 9.39% in the first half of 2015 to 5.57% in the first half of 2016 (蠂 ~ 2 / 157.10 / P0.01). (_ 3). The effective intervention measures included strengthening the awareness of hospital administrators and medical staff on the importance of the quality of the first page information of hospital records. Strengthen the study and training of the information filling rules of the first page of the medical record; optimize the information platform service of the front page of the medical record in the electronic medical record system; carry out and perfect the relevant examination system of the information quality of the front page of the medical record in the hospital; Perfect and optimize the reward and punishment mechanism of hospital information quality on the first page of hospital medical record.
【學(xué)位授予單位】：內(nèi)蒙古大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R197.323

【參考文獻(xiàn)】

相關(guān)期刊論文 前10條

1 吳良湘;;28家醫(yī)院病案首頁(yè)數(shù)據(jù)質(zhì)量調(diào)查分析[J];中國(guó)病案;2016年10期

2 周柳英;張靜;;品管圈在提高手術(shù)編碼準(zhǔn)確率中的應(yīng)用[J];中國(guó)病案;2016年05期

3 吳良湘;;信息化建設(shè)對(duì)病案首頁(yè)數(shù)據(jù)質(zhì)量的影響[J];中國(guó)病案;2016年03期

4 李準(zhǔn);宋萍;趙文龍;;病歷質(zhì)量現(xiàn)狀分析與對(duì)策[J];中國(guó)病案;2016年01期

5 徐惠霞;尤琳;紀(jì)恒勝;茍淑梅;;從編碼角度談病案中有關(guān)主要診斷與手術(shù)操作的書(shū)寫(xiě)質(zhì)控[J];齊魯醫(yī)學(xué)雜志;2015年06期

6 鐘勝;;病案首頁(yè)填寫(xiě)缺陷分析及實(shí)時(shí)控制[J];中國(guó)衛(wèi)生標(biāo)準(zhǔn)管理;2015年32期

7 宋桂花;夏靜;;1500份病案質(zhì)量缺陷分析[J];甘肅科技;2015年23期

8 湯艷雷;;電子病案首頁(yè)質(zhì)量存在的問(wèn)題及改進(jìn)意見(jiàn)[J];淮海醫(yī)藥;2015年06期

9 趙云;;新三醫(yī)聯(lián)動(dòng)模式下的醫(yī)療保險(xiǎn)付費(fèi)方式改革探討[J];醫(yī)學(xué)與社會(huì);2015年11期

10 張錦平;趙敏;張建華;;病案首頁(yè)的HQMS網(wǎng)絡(luò)直報(bào)錯(cuò)誤分析及改進(jìn)研究[J];中國(guó)病案;2015年10期

相關(guān)會(huì)議論文 前2條

1 黃培;李麗;李大祥;;PDCA循環(huán)法在提高病案首頁(yè)數(shù)據(jù)質(zhì)量中應(yīng)用[A];中國(guó)醫(yī)院協(xié)會(huì)病案管理專業(yè)委員會(huì)第二十四屆學(xué)術(shù)會(huì)議論文集匯編[C];2015年

2 李萍萍;;病歷書(shū)寫(xiě)基本規(guī)范解讀[A];中國(guó)醫(yī)院協(xié)會(huì)病案管理專業(yè)委員會(huì)第二十二屆學(xué)術(shù)會(huì)議論文集[C];2013年

，

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