[1]高宏富,赵 辉,关 雪.2019年河北省某医院住院病案首页质量填写的帕累托图分析[J].医学信息,2021,34(02):145-148.[doi:10.3969/j.issn.1006-1959.2021.02.040]
　GAO Hong-fu,ZHAO Hui,GUAN Xue.Pareto Chart Analysis of the Quality of the Front Page of Inpatient Medical Records in a Hospital in Hebei Province in 2019[J].Medical Information,2021,34(02):145-148.[doi:10.3969/j.issn.1006-1959.2021.02.040]
点击复制

2019年河北省某医院住院病案首页质量填写的帕累托图分析()
分享到：

医学信息[ISSN:1006-1959/CN:61-1278/R]

卷:
34卷
期数:
2021年02期
页码:
145-148
栏目:
调查分析
出版日期:
2021-01-15

文章信息/Info

Title:
Pareto Chart Analysis of the Quality of the Front Page of Inpatient Medical Records in a Hospital in Hebei Province in 2019
文章编号:
1006-1959（2021）02-0145-04
作者:
高宏富; 赵 辉; 关 雪
（联勤保障部队北戴河康复疗养中心，河北 秦皇岛 066100）
Author(s):
GAO Hong-fu; ZHAO Hui; GUAN Xue
(Joint Logistics Support Force Beidaihe Rehabilitation Center,Qinhuangdao 066100,Hebei,China)
关键词:
按疾病诊断相关分组; 病案首页; 质量; 帕累托图
Keywords:
Grouping by disease diagnosis; Front page of medical record; Quality; Pareto chart
分类号:
R19
DOI:
10.3969/j.issn.1006-1959.2021.02.040
文献标志码:
A
摘要:
目的 运用帕累托图分析病案首页主要缺项，探讨提高病案首页书写质量的方法。方法 抽取河北省联勤保障部队北戴河康复疗养中心2019年5月1日~10月31日共14309份出院病案，利用帕累托图分析法找出病案首页存在的主要缺项，并进一步分析缺项表现找到改进原因。结果 病案首页总缺陷份数为3791份，占到总抽查病历份数的52.65%。涉及4个部分信息，共计24个缺项项目。帕累托图显示，户口地址、血型及RH标识、婚姻、病理诊断和医生签字5个缺项为主要因素，累计构成比为76.63%。进一步分析发现，户口地址填写错误或空缺与医师工作量大、对信息系统不熟练及自身专业素养有关；血型及RH标识不匹配与检查结果缺漏和无相关检查有关，发生比率分别为23.45%和21.00%。结论 通过帕累托图分析得出某院住院病案首页质量填写有待提高，应积极加强科室及院内质控管理、开展多种样式培训，同时建立信息数据共享平台的方法提高病案首页质量。
Abstract:
Objective To analyze the main missing items in the front page of medical record by Pareto chart, and to explore the methods to improve the writing quality of the front page of medical record.Methods A total of 14,309 discharged medical records from Beidaihe Rehabilitation Center of Hebei Joint Logistics Support Force from May 1 to October 31, 2019 were collected, and the Pareto chart analysis method was used to find out the main deficiencies in the first page of the medical record and further analyze the lack of performance to find the reasons for improvement.Results The total number of defects on the front page of medical records was 3791, accounting for 52.65% of the total number of random medical records. There were 4 parts of information involved, 24 missing items in total. Pareto chart showed that the main factors were the address of household, blood type, RH mark, marriage, pathological diagnosis and doctor signature, with the cumulative proportion of 76.63%. Through in-depth analysis, it was found that the wrong or vacant registered address was related to the heavy workload of doctors, the unskilled information system and their own professional quality; the mismatching of blood type and RH identification was related to the lack of inspection results and the absence of relevant inspection. The incidence of these two projects was relatively high, 23.45% and 21.00% respectively.Conclusion Through Pareto chart analysis, it is concluded that the quality of the front page of inpatient medical records in a hospital needs to be improved. We should actively strengthen department and hospital quality control management, carry out various styles of training, and establish an information data sharing platform to improve the quality of medical records.

参考文献/References:

[1]王珊,杨兴宇,郎婧婧,等.全国按疾病诊断相关分组收付费在医院的应用探讨[J].中国医院管理,2017,37(6):5-7. [2]林德南,陶成琳,陈妍,等.深圳市C-DRG试点实施路径探讨[J].现代医院管理,2019,17(4):43-45. [3]常欢欢,杨兴宇,于丽华,等.C-DRG病案首页管理和质量控制[J].中国医院,2018,22(6):68-70. [4]赵学英,杨冬梅,王巍,等.住院病案首页数据编码质量的改进分析[J].中国病案,2016,17(6):136-137. [5]史赢,周生福,孙彤,等.住院病案首页信息缺陷帕累托图分析[J].中国病案,2017,18(10):21-24. [6]刘爱民.病案信息学[M].人民卫生出版社,2009:124-125. [7]许斌,梁宗敏,李文琦.住院病案首页质量控制[J].中国病案,2017,18(3):7-9. [8]林宝春.病案编码质量分析与改进对策[J].中国病案,2018,19(2):12-14. [9]曾祥嫚,官亚宜,杨毓芳,等.宁波市某三甲医院2013-2016年住院病例疾病构成分析[J].中国卫生统计,2017,34(6):964-966. [10]卢意来希,殷实,李林贵,等.宁夏回族自治区住院患者疾病构成分析[J].中国社会医学杂志,2018,35(4):403-407．

相似文献/References:

[1]郭筱萍.PDCA循环在提升病案首页信息质量的应用及持续改进[J].医学信息,2018,31(05):27.[doi:10.3969/j.issn.1006-1959.2018.05.010]
　GUO Xiao-ping.Application and Continuous Improvement of PDCA Circulation in Improving the Information Quality of First Page of Medical Record[J].Medical Information,2018,31(02):27.[doi:10.3969/j.issn.1006-1959.2018.05.010]
[2]张中花.病案首页书写缺陷分析及解决对策[J].医学信息,2019,32(06):29.[doi:10.3969/j.issn.1006-1959.2019.06.011]
　ZHANG Zhong-hua.Analysis of the Writing Defects on the Front Page of Medical Records and Solutions[J].Medical Information,2019,32(02):29.[doi:10.3969/j.issn.1006-1959.2019.06.011]
[3]李玉萍.疾病诊断名称与分类编码对照对提升病案首页质量的意义[J].医学信息,2020,33(09):17.[doi:10.3969/j.issn.1006-1959.2020.09.006]
　LI Yu-ping.Significance of the Comparison of Disease Diagnosis Name and Classification Code to Improve the Quality of the First Page of Medical Records[J].Medical Information,2020,33(02):17.[doi:10.3969/j.issn.1006-1959.2020.09.006]
[4]唐 路,宋 萍,谢冰珏,等.基于自主研发智能审核平台的病案首页质控效果评价[J].医学信息,2023,36(07):27.[doi:10.3969/j.issn.1006-1959.2023.07.005]
　TANG Lu,SONG Ping,XIE Bing-jue,et al.Evaluation of Quality Control Effect of Medical Records Front Pages Based on Self-developed Intelligent Audit Platform[J].Medical Information,2023,36(02):27.[doi:10.3969/j.issn.1006-1959.2023.07.005]
[5]窦一峰,崔金广,杨 洁,等.基于天津市某三甲医院的病案首页数据质量与DRGs评测分析[J].医学信息,2022,35(04):24.[doi:10.3969/j.issn.1006-1959.2022.04.007]
　DOU Yi-feng,CUI Jin-guang,YANG Jie,et al.Medical Case Home Page Data Quality and DRGs Evaluation Analysis Basedon a Tertiary Hospital in Tianjin[J].Medical Information,2022,35(02):24.[doi:10.3969/j.issn.1006-1959.2022.04.007]
[6]李 文.PDCA循环改进对提高胸科医院病案首页主要诊断正确率的影响[J].医学信息,2023,36(15):164.[doi:10.3969/j.issn.1006-1959.2023.15.035]
　LI Wen.Effect of PDCA Circulation Improvement on Improving the Main Diagnostic Accuracy of the Front page of Medical Records in Chest Hospital[J].Medical Information,2023,36(02):164.[doi:10.3969/j.issn.1006-1959.2023.15.035]
[7]胡志伟.基于PowerBI的病案首页可视化统计分析[J].医学信息,2023,36(21):21.[doi:10.3969/j.issn.1006-1959.2023.21.005]
　HU Zhi-wei.Visual Statistical Analysis of Medical Record Home Page Based on PowerBI[J].Medical Information,2023,36(02):21.[doi:10.3969/j.issn.1006-1959.2023.21.005]

更新日期/Last Update: 1900-01-01