Retrospective Analysis of the Data Quality of The Front Pages of TCM Medical Records Under the Background of The Performance Appraisal of Tertiary Public TCM Hospitals
Objectives The integrity and logic defects of data quality in the quality control process of the front page of medical records of a Provincial Three A and Tertiary Public were analyzed,and put forward effective improvement measures to provide the basis.Methods A total of 144,217 discharged TCM medical records from a hospital reported to the TCMMS from January 1st,2022 to December 31st,2023 were selected.Excel was used to count the details and proportion of defective items,and SPSS20.0 was used to conduct Chi-square test on the improvement of data filling quality.Results After the continuous quality control of the front page of medical records in 2023,the defect rate of the overall front page of medical records decreased from 8.67%in 2022 to 3.81%in 2023(χ2=1504.304,P＜0.001),among which,the completeness defect ratio of the front page of medical records decreased from 2.72%to 1.10%(χ2=10572.085,P＜0.001),and the proportion of missing TCM syndrome diagnosis name and code was the highest.The logical defect items decreased from 5.95%in 2022 to 2.72%(χ2=277.460,P＜0.001),and the proportion of missing TCM operations was the highest when the TCM treatment cost was greater than 0.Conclusions The data quality of the front page of medical records should be continuously improved by strengthening the training and lectures on the first page of medical records,comprehensive use of information technology,strengthening the functions of coders and quality control physicians,and innovating performance management.
TCM HospitalsMedical records quality controlPublic hospital performance appraisal
NETL
NSTL
万方数据
