首页|住院病案首页数据质量治理体系构建

住院病案首页数据质量治理体系构建

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目的 通过构建多要素协同的闭环管理体系,实现数据的全流程优化管理,提升住院病案首页数据质量.方法 本研究基于首页数据治理要素,从数据层、介质层、语义层、用户层进行规划,通过建立多部门联动的底层字典维护机制,引入智能化手段,建立自动编码应用模型,开发首页医生端和编码端智能质控功能模块,构建全流程闭环管理体系.结果 该体系显著提高了病案首页数据的准确性、完整性和上报效率,解决了质量评估滞后问题.结论 系统化、智能化的全流程数据治理策略,为提升住院病案首页数据质量提供了有效路径,对推动医院精细化管理及高质量发展具有重要价值.
Construction of a Data Quality Governance System for the Inpatient Medical Record Home Page Data
Objective To enhance the quality of inpatient medical record home page data (IMRHPD),this study implements a comprehensive optimization strategy by developing a closed-loop management system that integrates multiple elements. Methods This study addresses IMRHPD governance across four layers—data,media,semantic,and user. A multi-departmental linkage mechanism is established to maintain underlying dictionaries,while an automated coding application model is introduced through intelligent technologies. Additionally,intelligent quality control modules are developed for both the medical and coding sides. Build a closed-loop management system for the whole process. Results The implemented system markedly improves the accuracy,completeness,and reporting efficiency of IMRHPD,effectively addressing previous delays in quality assessment. Conclusion This systematic and intelligent data governance strategy provides a robust framework for enhancing IMRHPD quality,offering significant potential for advancing hospital management and promoting high-quality development in the future.

inpatient medical record home pagedata governancequality

周婧雅、王怡、谢雨涵、李博诚、李乃适

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中国医学科学院北京协和医院病案科(WHO国际分类家族中国合作中心),北京市,100730

住院病案首页 数据治理 质量

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(6)