基于2414份住院病案首页数据缺陷分析及干预前后效果评价

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Abstract Objective To analyze the reasons for the defects of data in the homepage of hospitalization medical records and take some intervention measures so as to observe the improvement effect of the data and the coding quality in the homepage of the medical records before and after the intervention.Methods The coding for the home page of hospitalization medical records from September 2015 to March 2016 in our hospital was retrospectively reviewed.Altogether 1207 medical records were randomly selected as the pre-intervention group to find out the defects of the coding quality in the homepage of the medical records.The reasons for the defects were summarized and analyzed.After strengthened training of the clinicians and coders in our hospital,1207 hospitalization medical records from January to June in 2017 were randomly selected as the post-intervention group.The data and coding quality of 1207 hospitalization medical records were compared before and after training.Results The medical record defect rate of the pre-intervention group and post-intervention group was 76.5%and 15.9%,respectively.The data and coding quality of the homepage of the medical records in the post-intervention group were significantly higher than those in the pre-intervention group (P＜0.01).The main items of the coding defect included the missing or wrong basic information,error information in doctor′s main diagnosis and selection,missing or wrong surgical and operation information,and other information errors in the homepage of the medical records.Conclusion The coding defects in the front page of medical records is found through inductive analysis.And the policy of strengthening the responsibility of the clinicians is formulated to strengthen the training and study of how to fill in the homepage of the medical records,communication between the coders and the doctors,and management of the coding process of the medical records.It is the key to improve the coding quality of the homepage of the medical records,and also a bridge to establish good communication between the clinician and the medical record coders.

Key words： Homepage of the medical records Data defect Intervention Effect evaluation

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	LI Xiao-dan
	XU Ming-dong

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LI Xiao-dan,XU Ming-dong. Defect analysis based on homepage data of 2414 hospitalization medical records and pre-and post-interventional effect evaluation[J]. 中国当代医药, 2018, 25(14): 148-151.

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http://dangdaiyiyao.com/EN/ OR http://dangdaiyiyao.com/EN/Y2018/V25/I14/148

[1]	王丽萍，王娅，江黎.病案首页信息缺陷分析及改进措施[J].中国病案，2016，17（2）：19-21.
[2]	赵正慧，梁瑞文，李兵，等.PDCA循环在ICD编码质量管理的应用[J].中国病案，2017，18（6）：32-35.
[3]	孙晓佳.病案首页填写存在问题及改进措施[J].实用医药杂志，2011，28（2）：182-183.
[4]	吴文健，刘颖.住院病案首页疾病分类编码分析与改进[J].中国病案，2016，17（7）：19-21.
[5]	于龙广，朱兆芳，林明霞.住院病案首页数据质量缺陷分析及对策[J].中国病案，2017，18（8）：13-15.
[6]	梁碧珍，周英华，邹丽荣，等.降低病案ICD编码错误率，提高病案管理质量[J].当代医学，2015，21（14）：12-13.
[7]	谢佳东，赵玉凤，胡孔法，等.国内中医住院病案首页质量分析与影响因素初探[J].中国中医药信息杂志，2016，23（12）：6-10.
[8]	郑立希.中医病案首页缺陷探讨[J].中国病案，2017，18（7）：18-21.
[9]	赵慧智，王永锋，杨利谦，等.病案首页质量分析与改进措施研究[J].中国病案，2017，18（2）：14-17.
[10]	许斌，梁宗敏，李文琦.住院病案首页质量控制[J].中国病案，2017，18（3）：7-9.
[11]	杨星.某市二级及以上医院病案首页质量分析[J].中国病案，2017，18（5）：19-22.
[12]	赵学英，杨冬梅，王巍，等.住院病案首页数据编码质量的改进分析[J].中国病案，2016，17（6）：4-6.
[13]	阮鹤瑞，刘晓明，金疆山，等.病案首页填写缺陷分析及对策建议[J].中国病案，2015，16（2）：20-24.
[14]	王文君.住院医师病案首页填写质量影响因素及干预对策研究[D].合肥：安徽医科大学，2015.
[15]	宁传英.5000份住院病案首页质量缺陷分析[J].中国病案，2016，17（11）：31-33.