[1]胡远樟,朱必刚,何雅兰,等.某市公立医疗机构病案质量管理现状调查分析[J].医学信息,2023,36(03):18-21.[doi:10.3969/j.issn.1006-1959.2023.03.005]
　HU Yuan-zhang,ZHU Bi-gang,HE Ya-lan,et al.Investigation and Analysis on the Status Quo of Medical Record Quality Management in Public Medical Institutions in A City[J].Journal of Medical Information,2023,36(03):18-21.[doi:10.3969/j.issn.1006-1959.2023.03.005]
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某市公立医疗机构病案质量管理现状调查分析()
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医学信息[ISSN:1006-1959/CN:61-1278/R]

卷:
36卷
期数:
2023年03期
页码:
18-21
栏目:
卫生管理信息学
出版日期:
2023-02-01

文章信息/Info

Title:
Investigation and Analysis on the Status Quo of Medical Record Quality Management in Public Medical Institutions in A City
文章编号:
11006-1959（2023）03-0018-04
作者:
胡远樟; 朱必刚; 何雅兰; 等
（宜宾市第一人民医院病案统计科，四川 宜宾 644000）
Author(s):
HU Yuan-zhang; ZHU Bi-gang; HE Ya-lan; et al.
(Department of Medical Records Statistics,the First People’s Hospital of Yibin,Yibin 644000,Sichuan,China)
关键词:
病案首页质量; 公立医疗机构; DRGs; 管理现状
Keywords:
Quality of medical records; Public medical institutions; DRGs; Management status
分类号:
R197.323
DOI:
10.3969/j.issn.1006-1959.2023.03.005
文献标志码:
A
摘要:
目的 了解某市公立医疗机构病案质量管理现状，为病案质量的管理及提高提供现实依据。方法 随机抽取2020年10月1日-2021年3月31日某市16家二级及以上公立医疗机构，通过开展病案质量及首页质控统计病案首页数据质量与控制、病案管理、病案质量管理等5个大类，17个小类指标，并运用描述性统计对指标结果进行分析。结果 被调查的16家公立医疗机构中，近70.00%机构的病案归档率低于国家要求，专业病案管理人员与病床配比为0.72∶50，远低于国家要求的1∶50；30.00%以上的机构主要诊断、手术、操作选择及编码正确率低于其平均值等问题。结论 某市公立医疗机构病案首页质量及管理仍需进一步改进，各级医疗机构应重视病案首页的质量，加强对相关人员的培训，充分利用现代信息化技术手段建立质控体系，以提高病案首页质量。
Abstract:
Objective To understand the status quo of medical record quality management in public medical institutions in a city, and to provide a realistic basis for the management and improvement of medical record quality.Methods From October 1, 2020 to March 31, 2021, 16 secondary and above public medical institutions in a city were randomly selected. Through the development of medical record quality and home page quality control statistics, the data quality and control of medical record home page, medical record management, medical record quality management and other 5 categories, 17 sub-categories of indicators, and descriptive statistics were used to analyze the results of the indicators.Results Among the 16 public medical institutions surveyed, nearly 70.00% of the institutions’ medical record filing rate was lower than the national requirements. The ratio of professional medical record managers to beds was 0.72∶50, which was much lower than the national requirement of 1∶50. More than 30.00% of the institutions had problems such as main diagnosis, surgery, operation selection and coding accuracy lower than their average.Conclusion The quality and management of the first page of medical records in a public medical institution in a city still need to be further improved. Medical institutions at all levels should pay attention to the quality of the first page of medical records, strengthen the training of relevant personnel, and make full use of modern information technology to establish a quality control system, so as to improve the quality of the first page of medical records.

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更新日期/Last Update: 1900-01-01