逻辑校验质控点在提高住院病案首页质量中的应用

目的 分析设置电子校验质控点前后住院病案首页质量变化的情况.方法 2018年11月1日-2019年5月31日为改进前,2019年6月1日-2019年11月30日为改进后,按照每月临床科室出院病案的2％从2个时间段各随机选取1093份住院病案首页共计2186份作为研究对象.改进包括增加逻辑校验、提醒拦截设置和信息自动填入...

The Application of Logic Check Quality Control Point in Improving the Quality of the Front Page of Inpatient Medical Records

Objective To analyze the quality change of the first page of inpatient medical records before and after setting up electronic check quality control point. Methods After the improvement from November 1 st, 2018 to May 31 st, 2019, 1,093 inpatient medical records(2186 in total) were randomly selected from two periods of time according to 2% of the monthly discharge records of clinical departments. The improvement includes the addition of logic check, reminder interception setting and automatic information filling, the quality control evaluation was carried out according to the Detailed Rules of Quality Control and Assessment on the front page of Chinese Medicine Inpatient Medical Records(2017 edition), and the statistical software SPSS20.0 was used to analyze the result data. Results Among the 31 items that must be filled in the front page, the defect rate of the front page of the medical records was 11.83% and 10.59%. Among them, the diagnosis and treatment information of the defect items before improvement accounted for 38.65%, the basic information of patients accounted for 28.64%, the information of the hospitalization process accounted for 16.08%, and the cost information accounted for 16.42%. Diagnosis and treatment information of backyard defect improvement project accounted for 41.32%, basic information of patients accounted for 26.58%, information of hospitalization process accounted for 15.68%, and cost information accounted for 16.42%. The average score of data quality management and control index on the front page of medical records of traditional Chinese medicine hospital was 68.34 before improvement and 75.81 after improvement. Conclusions Setting up electronic check quality control point could obviously improve the quality of the front page of inpatient medical records and reduce the error rate, which was worthy of further promotion.