首页|网格化管理在住院病案首页数据质量控制中的应用

网格化管理在住院病案首页数据质量控制中的应用

Grid management for improving data quality control on the front page of inpatient medical records

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目的 运用网格化管理单元模式,提升住院病案首页数据质量.方法 组织10名编码员对实施网格化管理前后的住院病案首页的基本信息、诊疗信息、住院过程信息进行人工质控及结合系统校验规则.结果 实施前728份住院病案首页中有808项缺陷,其中基本信息、诊疗信息、过程信息分别占40.84%、3.96%、55.20%.实施后796份住院病案首页中有282项缺陷,其中基本信息、诊疗信息、过程信息分别占39.00%、7.80%、53.19%.实施后总体缺陷率较实施前下降,差异具有统计学意义(x2=6.553 5,P<0.05).实施后住院病案首页缺陷内容中入院病情、身份证号填写不规范、切口愈合等级、编码错误或不符合编码较验规则项次均少于实施前,差异有统计学意义(P<0.05);身份证号的规范性实施后实现了清零,达到了明显的效果.结论 网格化管理在提升住院病案首页数据质量方面缩短了传达及反馈时间,提高解决问题的效率,有利于住院病案首页数据质量的联动控制,从而使得住院病案首页的规范性、一致性、完整性、逻辑性四个方面得到提升.网格化管理也可以推广到医院的其他管理领域,为优化医院管理流程提供科学的管理模式.
Objective To enhance the data quality of the front page of inpatient medical records.Methods Ten coders were engaged to perform manual quality control,and system verification rules were integrated for the basic information,diagnosis,treatment information,and hospitalization process information on the front page of inpatient medical records before and after the implementation of grid management.Results A total of 808 defects were found on the front pages of 728 inpatient medical re-cords.Among these deficiencies,basic information,diagnosis and treatment information,and process information accounted for 40.84%,3.96%,and 55.20%respectively.Totally,282 defects on the front pages of the 796 inpatient medical records man-aged under grid management.Among them,basic information,diagnosis and treatment information,and process information ac-counted for 39.00%,7.80%,and 53.19%,respectively.The overall defect rate was significantly decreased under grid manage-ment compared to the rate without it,(x2=6.553 5,P<0.05).After the implementation of grid management,the numbers of the defects in admission condition,ID number incompletion,incision healing status,and coding were significantly decreased(P<0.05).After the normalized coding of the ID number,the defect in ID number incompletion on the pages disappeared con-sequently.Conclusion Grid management reduces communication and feedback time,improves the data quality of the front page of inpatient medical records,and enhances problem-solving efficiency.It is important to coordinate the control of the data on the front pages of inpatient medical records to enhance standardization,consistency,and integrity.Moreover,it can also be applied to other areas of hospital management,offering scientific methods to optimize overall hospital operations.

Grid managementManagement unitFront page of inpatient medical recordsData quality

廖慧群、杨爱群、吴新飞

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深圳市光明区人民医院 广东深圳 518106

深圳市龙岗区第三人民医院 广东深圳 518115

网格化 管理单元 住院病案首页

深圳市光明区经济发展专项深圳市光明区人民医院管理类科研课题深圳市光明区人民医院管理类科研课题

2021R0113820230122023001

2024

现代医院
广东省医院协会

现代医院

影响因子:1.332
ISSN:1671-332X
年,卷(期):2024.24(3)
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