|
|
|
| Problems and rectification analysis of filling in medicine expenses and treatment information on the first page of traditional Chinese medicine medical records |
| WANG Liqin1 GU Jing2▲ |
1.Department of Medical Records,Lishui Hospital of Traditional Chinese Medicine,Jiangsu Province,Nanjing 211200,China;
2.Department of Medical Records,Nanjing Gaochun District People's Hospital,Jiangsu Province,Nanjing 211300,China |
|
|
|
|
Abstract Objective The Chinese medicine cost information,diagnosis and treatment information on traditional Chinese medicine medical record homepage appeared error in the logical verification.Based on the phenomenon,this study analyzes the causes of logical verification errors in the front page of traditional Chinese medicine medical records in Lishui Hospital of Traditional Chinese Medicine,and puts forward rectification measures.Methods According to the rules for filling out the first page of traditional Chinese medicine medical record homepage and comparing with the performance interface standards of national public hospitals,a logical verification report for the first page of medical records was developed in the medical record management system.The archived medical records were obtained from January 2019 to December 2020.Firstly,this study performed verification according to the treatment category and Chinese medicine fee.Subsequently,the medical institution preparations filling and medical institution preparations fees were used for verification.Finally,the rule of Chinese medicine diagnosis and treatment technology to formulate and Chinese medicine(Chinese medicine and ethnic medicine medical services)are applied for verification.The data statistically analyzed that the departments had logical verification problems and the cost of each department was logically verified wrong.Results Among all archived medical records from January 2019 to December 2020,16 departments involved logical verification problems.During this period,24 158 medical records were filed from the 16 departments of the hospital and there were logical verification errors in 5121 medical records,accounting for 21.20%.The proportion of medical records with incorrect verifications of treatment categories and hospitalization expenses was 24.51%,41.20%of the medical records filled in with medical institutions' preparations and verified with medical institutions' preparation fees incorrectly.Additionally,the medical records with incorrect diagnosis and treatment technology and Chinese medicine(Chinese medicine and ethnic medicine medical services)that was checked incorrectly was also accounted for 34.29%.Conclusion The comparison of hospitalization expenses on the first page of traditional Chinese medicine medical records in Lishui District Hospital of traditional Chinese medicine needs to be improved.It is necessary to strengthen the communication with medical insurance department and clinical department to ensure the timeliness and accuracy of hospitalization expenses comparison.At the same time,logical verification is added to the link of clinicians writing medical records,so as to improve the writing quality of medical records and reduce the revise rate of paper medical records.
|
|
|
|
|
|
| [1] |
孙如鹏，路文亮，丁雅霜.病历全面质量管理的实践[J].中国社区医师（医学专业），2012，14（24）：332，334.
|
| [2] |
房洪军，张渺，孙璐，等.构建全方位病历质控体系[J].中国卫生质量管理，2016，23（2）：36-38.
|
| [3] |
郝育鹏，季新强，刘晶.逻辑校验在住院病案首页填报中的作用[J].中国医院管理，2018，38（11）：42-43，46.
|
| [4] |
全国卫生资源及医疗服务调查制度[EB/OL].http://www.nhc.gov.cn/mohwsbwstjxxzx/s8560/200809/37814.shtml，2007-07-16.
|
| [5] |
戴保玲.公立中医医院绩效考核中病案首页质量问题分析及改进措施[J].中国民间疗法，2020，28（12）：104-105.
|
| [6] |
何毅，卢瑶，江磊，等.病案首页智能化填写运用探讨[J].中国病案，2017，18（4）：57-60.
|
| [7] |
钟珣，郑洁，谈世凤，等.基于三级公立医院绩效考核的住院病案首页质控效果评价[J].中国病案，2020，21（2）：25-27，112.
|
| [8] |
中华人民共和国国家卫生和计划生育委员会，国家中医药管理局.病历书写基本规范（试行）[J].中国医院，2002，6（10）：54-57.
|
| [16] |
梁喜，刘丹丹.住院病案首页质量影响因素与对策分析[J].中国医药科学，2020，10（8）：212-215.
|
| [9] |
中华人民共和国卫生部.卫生部关于修订住院病案首页的通知[J].中华人民共和国卫生部公报，2011，9（12）：14-22.
|
| [10] |
王楠楠.逻辑校验质控点在提高住院病案首页质量中的应用[J].中国病案，2021，22（1）：35-38.
|
| [11] |
万金兰，陈丹.三级公立中医医院绩效考核对住院病案首页数据质量的影响[J].中国病案，2021，22（3）：19-22.
|
| [12] |
张琴，李晓东，曹玉龙，等.终末住院病案首页多环节质量监控[J].中国病案，2020，21（4）：31-33，44.
|
| [13] |
高丹红，沈银忠，李申扬，等.住院病案首页填写培训的效果评价[J].中国病案，2020，21（7）：21-24.
|
| [14] |
李永富.某院中医住院病案首页缺陷分析与对策[J].中国医院统计，2014，21（2）：100-102.
|
| [15] |
郭立华.医院中医病案首页质量分析与影响因素[J].中国民间疗法，2020，28（13）：89-91.
|
|
|
|
