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目的通过分析某院现有的住院病案首页修正数据,归纳住院病案首页数据修正的主要原因,探索提升某院住院病案首页数据质量的措施。方法根据国家卫生计生委《住院病案首页数据填写质量规范(暂行)》等文件规定,对某院电子病历系统中记录的2016年1月-6月共6504份住院病案首页修正申请进行统计,并分析其申请原因。结果 2016年一季度住院病案首页修正申请共4058份,修正项目构成中出院时间占14.1%,出院诊断占24.5%,手术信息占10.3%,入院途径占22.3%,病理缺失占5.7%,其他内容占23.1%。在充分调研和数据分析的基础上,二季度某院在管理方式、责任意识、信息化建设三个层面实施了一系列的改进措施。改进后的某院二季度住院病案首页修正申请共2446份,其修正项目构成情况为:出院时间占11.3%,出院诊断占21.7%,手术信息占9.4%,入院途径占26.4%,病理缺失占8.7%,其他内容占22.5%。结论将住院病案首页填写情况进行监控,并针对监控所反映的问题实施相应的改进措施,有助于完善医院住院病案首页管理方式,提高医师填写住院病案首页的责任意识,促进住院病案首页填写的信息化建设,是确保住院病案首页数据质量的有效途径。
Objective To analyze the main data of the first page of hospitalized medical record by analyzing the data of the first page of the existing hospitalized medical record in a hospital and to explore the measures to improve the data quality of the first page of inpatient medical record in a hospital. Methods According to the regulations of the State Health and Family Planning Commission, “Home Quality Data of Inpatient Medical Records (Interim)” and other documents, a total of 6504 inpatient medical records homepage revision applications recorded in a hospital electronic medical record system were counted and compared between January 2016 and June 2016 Analysis of the reasons for their application. Results In the first quarter of 2016, there were 4058 first revision applications for inpatient medical records, 14.1% for discharged items, 24.5% for discharged items, 10.3% for surgical information, 22.3% for admission, and 5.7% for pathological changes. Other contents Accounting for 23.1%. On the basis of full investigation and data analysis, a certain hospital in the second quarter implemented a series of improvement measures in three aspects: management style, sense of responsibility and information construction. The revised first home in the second quarter of a hospital inpatient medical records a total of 2446 amendments to the application, the correction of the composition of the project are: discharge time accounted for 11.3%, 21.7% discharged diagnosed, surgical information accounted for 9.4%, 26.4% of admission, pathological loss 8.7%, other content accounted for 22.5%. Conclusion The first page of inpatient medical records to monitor the situation, and the monitoring of the problems reflected in the implementation of the corresponding improvements will help improve the hospital inpatient medical records home page management approach to improve physicians fill in the first page of hospitalized patients’ sense of responsibility to promote the first page of hospitalized medical records filled Informatization construction is an effective way to ensure the data quality of the first page of inpatient medical record.