Abstract:Objective To analyze the management and data quality of the first page of medical records of public hospitals in Leshan, and put forward some suggestions for the existing problems.Methods Fifty medical records of discharged patients in 2021 were randomly selected from 14 hospitals, and quality control was carried out one by one according to the "data quality scoring standards for the first page of inpatient medical records", data defects of the first page of medical records were analyzed, and the data filling process and management of medical records on the first page of medical records were investigated by combining quantitative and qualitative methods.Results Defects in quality control medical records accounted for 45.3%; among the data on the first page of medical records that affected performance assessment monitoring indicators, the defects of admission condition, diagnosis and code, surgical operation and code, and incision healing grade accounted for a relatively high proportion. There were weak points in data collection, quality control and interface reporting on the first page of medical records.Conclusion All medical institutions should further sort out the problems in all links of data filling on the home page and strengthen quality control assessment and construction management for data defects and weak links.
荆媛,黄琪,周凤飞. 绩效考核背景下公立医院病案首页数据填报现状研究[J]. 中国医院统计, 2023, 30(2): 148-151.
Jing Yuan,Huang Qi,Zhou Fengfei. Research on the present situation of the first page data filling of medical records in public hospitals under the background of performance appraisal. journal1, 2023, 30(2): 148-151.