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智能病案首页质控系统的应用效果评价

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目的 评价智能病案首页质控系统对病案首页质量的影响.方法 采用间断时间序列模型(ITS)分析系统使用前(2021年1月—2022年8月)与使用后(2022年9月—2023年10月)某医院主要诊断选择正确率、主要诊断编码正确率、主要手术选择正确率、主要手术编码正确率、疾病诊断相关分组(DRG)入组率和病案首页完整率等6项评价指标的变化情况.结果 ITS模型分析结果显示,在智能病案首页质控系统使用后,主要诊断选择正确率、主要诊断编码正确率、主要手术选择正确率、主要手术编码正确率和病案首页完整率均呈明显的上升趋势,总体改变量分别上升0.665%、0.437%、0.426%、0.538%、0.381%,但对DRG入组率变化趋势影响不明显.结论 智能病案首页质控系统可显著改善病案首页质量,具有较好的应用前景和推广价值.
Evaluation of the Application Effectiveness of Intelligent Medical Record Homepage Quality Control System
Objective Evaluate the impact of the intelligent medical record homepage quality control system on the quality of the medical record homepage.Methods Using the interrupted time series model(ITS)to analyze the changes in six evaluation indicators,including the accuracy of primary diagnosis selection,primary coding accuracy,primary surgical selection accuracy,primary surgical coding accuracy,diagnosis related groups(DRG)enrollment rate,and medical record homepage completeness,before the use of the system(January 2021 August 2022)and after the use of the system(September 2022 October 2023)in a certain hospital.Results The ITS model analysis results showed that after the use of the intelligent medical record homepage quality control system,the main diagnostic selection accuracy,main coding accuracy,main surgical selection accuracy,main surgical coding accuracy,and medical record homepage completeness rate all showed a significant upward trend,with overall variables increasing by 0.665%,0.437%,0.426%,0.538%,and 0.381%,respectively.However,the impact on the DRG inclusion rate change trend was not significant.Conclusion The intelligent medical record homepage quality control system has a significant improvement effect on the quality of medical record homepage,and has good application prospects and promotion value.

medical record homepagequality controlinterrupted time series model

康周、谷成胜、马崇淇

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广元市中心医院,四川省广元市,628000

病案首页 质量控制 ITS模型

四川省医院协会2023年医院管理科研专项资金项目

YG2328

2024

中国卫生信息管理杂志
卫生部统计信息中心

中国卫生信息管理杂志

CSTPCD
影响因子:1.2
ISSN:1672-5166
年,卷(期):2024.21(5)
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