住院病案首页数据质量控制体系建设

目的探索并建立住院病案首页数据采集质量控制体系,完整、准确地采集病案首页信息,为诊疗服务效果评价、制定疾病防控策略、实施科学管理等提供科学依据。方法提取2017年1月1日至2017年12月31日上报到国家卫生统计直报系统的部分二级及以上医院(共8163家)住院病案首页数据,建立质量控制体系。从一致性、完整性、逻辑性和规范性四个方面进行数据质量评估。结果二级以上医院机构病案首页报送率71.6%,出现缺填较多的指标不完整率在11.0%以内(除“出院病房”不完整率为26.3%外);出现逻辑错误较多的指标不合逻辑率在14.3%以内;出现不规范问题较多的指标不规范率在5.8%以内。结论建立住院病案首页数据采集质量控制体系,提高数据上报效率,使得病案首页填写更加规范、准确,为诊疗服务效果评价、制定疾病防控策略提供科学依据。

The Building of Quality Control System on Data Collection of Front Sheet of Inpatient Medical Records

Objective To explore and establish the quality control system of data collection on front sheet items of inpatient medical records in order to collect the information completely and exactly and to provide a reference for effect evaluation on medical service,instituting of strategy on disease control and prevention,implement scientific management. Methods To establish the quality control system model on front sheet items of inpatient medical records according to the quality data evaluation of the front sheet of inpatient medical records reported from January 1,2017 to December 31,2017. Results The report rate of the medical record is 71.6% in secondary and above hospitals,and the incomplete rate of indicators is within 11.0%(except for “discharge ward” of 26.3%);The logic rate is within 14.3%;the index non-standardization rate is within 5.8%. Conclusion Establishing the quality control system for data collection on inpatient medical records will improve the efficiency of data collecting make inpatient medical records more standardized and accurate,and provide a scientific basis for evaluating the effect of diagnosis and treatment services and formulating disease prevention and control strategies.