【摘要】：住院病案首頁信息是患者在醫(yī)院住院醫(yī)療過程中全部信息的濃縮精華,目前住院病案首頁信息經(jīng)常存在缺項、漏項、填寫錯誤等質(zhì)量問題。為了提高信息質(zhì)量,本文對某醫(yī)院2015年上半年的住院病案首頁信息質(zhì)量現(xiàn)狀進行了評價、對醫(yī)院內(nèi)全部住院醫(yī)師進行了問卷調(diào)查、對病案管理委員會成員進行了專家訪談以及組成品管圈小組。利用描述性統(tǒng)計分析、根因分析、非條件Logistic回歸分析等方法,分析了住院病案首頁信息質(zhì)量的影響因素,制定并實施了干預(yù)對策,在干預(yù)對策實施6個月后,對2016年上半年與2015年上半年的住院病案首頁信息質(zhì)量進行了對比分析。研究結(jié)果表明:(1)住院病案首頁信息質(zhì)量的主要影響因素包括對首頁質(zhì)量重視度不夠、培訓次數(shù)少、病歷系統(tǒng)不完善、自查率低、獎勵力度小;(2)干預(yù)對策實施6個月后,住院醫(yī)師填寫住院病案首頁信息不合格率由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)對策包括加強醫(yī)院管理人員與醫(yī)務(wù)人員對住院病案首頁信息質(zhì)量重要性的認識;加強住院病案首頁信息填寫規(guī)則的學習、培訓;優(yōu)化電子病歷系統(tǒng)中住院病案首頁的信息平臺服務(wù);執(zhí)行和完善醫(yī)院對住院病案首頁信息質(zhì)量的相關(guān)考核制度;完善和優(yōu)化醫(yī)院對住院病案首頁信息質(zhì)量的獎懲機制等。
[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.
【學位授予單位】：內(nèi)蒙古大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R197.323

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