基于PDCA法提升住院病案首页信息质量的对策研究

发布时间：2018-07-20 14:18

【摘要】：住院病案首页信息是患者在医院住院医疗过程中全部信息的浓缩精华,目前住院病案首页信息经常存在缺项、漏项、填写错误等质量问题。为了提高信息质量,本文对某医院2015年上半年的住院病案首页信息质量现状进行了评价、对医院内全部住院医师进行了问卷调查、对病案管理委员会成员进行了专家访谈以及组成品管圈小组。利用描述性统计分析、根因分析、非条件Logistic回归分析等方法,分析了住院病案首页信息质量的影响因素,制定并实施了干预对策,在干预对策实施6个月后,对2016年上半年与2015年上半年的住院病案首页信息质量进行了对比分析。研究结果表明:(1)住院病案首页信息质量的主要影响因素包括对首页质量重视度不够、培训次数少、病历系统不完善、自查率低、奖励力度小;(2)干预对策实施6个月后,住院医师填写住院病案首页信息不合格率由2015年上半年的29.32%显著下降到2016年上半年的10.14%(χ2=1741.65,P0.01)。病案编码员对疾病和手术操作编码不合格率由2015年上半年的9.39%下降到2016年上半年的5.57%(χ2=157.10,P0.01)。(3)有效干预对策包括加强医院管理人员与医务人员对住院病案首页信息质量重要性的认识;加强住院病案首页信息填写规则的学习、培训;优化电子病历系统中住院病案首页的信息平台服务;执行和完善医院对住院病案首页信息质量的相关考核制度;完善和优化医院对住院病案首页信息质量的奖惩机制等。
[Abstract]:The first page information of the medical record is the essence of all the information of the patient in the course of hospital medical treatment. At present, there are many quality problems in the front page of the medical record of the hospital, such as missing items, filling out mistakes, and so on. In order to improve the quality of information, this paper evaluates the present situation of the first page of a hospital's medical record in the first half of 2015, and makes a questionnaire survey on all resident physicians in the hospital. The members of the Medical record Management Committee were interviewed by experts and formed a quality control group. By means of descriptive statistical analysis, root cause analysis, non-conditional logistic regression analysis, this paper analyzed the factors affecting the information quality of the first page of the medical record, formulated and implemented the intervention countermeasures, and implemented the intervention countermeasures 6 months after the implementation of the intervention measures. The information quality of the first half of 2016 and the first half of 2015 was compared. The results show that: (1) the main influencing factors of the information quality of the first page of the medical record include insufficient attention to the quality of the first page, less training, imperfect medical record system, low self-examination rate and small incentive; (2) six months after the implementation of the intervention countermeasures, The rate of failing to fill out the first page of the medical record of the resident decreased significantly from 29.32% in the first half of 2015 to 10.14% in the first half of 2016 (蠂 ~ 2 / 1741.65p ~ (0.01). The unqualified rate of disease and operation codes was reduced from 9.39% in the first half of 2015 to 5.57% in the first half of 2016 (蠂 ~ 2 / 157.10 / P0.01). (_ 3). The effective intervention measures included strengthening the awareness of hospital administrators and medical staff on the importance of the quality of the first page information of hospital records. Strengthen the study and training of the information filling rules of the first page of the medical record; optimize the information platform service of the front page of the medical record in the electronic medical record system; carry out and perfect the relevant examination system of the information quality of the front page of the medical record in the hospital; Perfect and optimize the reward and punishment mechanism of hospital information quality on the first page of hospital medical record.
【学位授予单位】：内蒙古大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.323

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