中国医院管理2024,Vol.44Issue(2) :72-74.

住院病案首页附页数据质量评分标准清单研究——基于AHIMA数据质量管理模型

Research on the List of Data Quality Scoring Criteria for the Attached Sheet to the Summary Page of Inpatient Cases Based on AHIMA's Data Quality Management Model

孙扬 姜垚松 孟诚真 舒琴 徐小兵 胡赛 李迪
中国医院管理2024,Vol.44Issue(2) :72-74.

住院病案首页附页数据质量评分标准清单研究——基于AHIMA数据质量管理模型

Research on the List of Data Quality Scoring Criteria for the Attached Sheet to the Summary Page of Inpatient Cases Based on AHIMA's Data Quality Management Model

孙扬 1姜垚松 1孟诚真 2舒琴 1徐小兵 1胡赛 1李迪1
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作者信息

  • 1. 武汉市中心医院 湖北 武汉 430014
  • 2. 华中科技大学同济医学院附属协和医院 湖北 武汉 430022
  • 折叠

摘要

目的 构建住院病案首页附页数据质量评分标准清单,以实现附页数据质量的定量评价.方法 以美国健康信息管理协会数据质量管理模型为框架制定附页数据质量评分标准清单,并对湖北省卫生健康委发布的《住院病案首页附页》进行评分以展示该清单的应用.结果 《住院病案首页附页》40个数据项目的平均得分为6.725分.主要质量缺陷体现在所有项目都没有明确填写责任人,也未明确定义填报时限.此外,部分项目与首页项目重复(占35%)或不具有摘要性质(占40%).结论 住院病案首页附页数据质量仍有较大的提升空间,特别是在设置附页项目时应明确填报责任人和填报时限,对首页项目起到补充和延展的作用,并应用有效的质量控制手段.

Abstract

Objective To construct a list of quality scoring criteria for the attached sheet to the summary page of inpatient cases to achieve quantitative evaluation of the data quality.Methods It uses the Data Quality Management model of the American AHIMA as the evaluation framework to develop the list of data quality scoring criteria for the attached sheet,and score in Attached Sheet to the Summary Page of Inpatient Cases issued by the Hubei Provincial Health Commission as a demonstration.Results The average score of the 40 items in Attached Sheet to the Summary Page of Inpatient Casesis 6.725 out of 10.The main quality defects include that all items fail to clarify the person responsible for filling or the time limit for filling.In addition,some items are duplicated with the summary page(35%)or do not have a summary nature(40%).Conclusion Significant room exists for the improvement in the data quality of the attached sheet,especially in defining the person responsible and the time limit for filling in when setting up the items,making sure that the items supplement and extend the summary page,and applying effective quality control methods to the items.

关键词

数据质量管理/评分标准/住院病案首页附页

Key words

Data Quality Management/scoring criteria/attached sheet to the summary page of inpatient cases

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出版年

2024
中国医院管理
中国医院管理杂志社

中国医院管理

CSTPCD北大核心
影响因子:2.15
ISSN:1001-5329
参考文献量8
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