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| Application of office automation in the quality management of operation related data on the front page of medical records |
| Li Jizhi，Zhu Zhonghua，Liu Renying |
People's Hospital of Liangping District, Chongqing 405200, China
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Abstract Objective To analyze the application effect of office automation (OA) in the quality management of operation related data on the front page of medical records, and to provide practical basis for the innovation of operation related information management mode on the front page of medical records. Methods From September 2018 to August 2019 (the first stage), 13 004 cases of operation related information on the front page of medical records were selected as the control group, and the routine management method was used; from September 2019 to August 2020 (the second stage), 13 306 cases of operation related data on front page of medical records in the whole hospital were taken as the experiment group, and on the basis of conventional management methods, OA mobile terminal of medical record management was added. The two groups were compared on the missing rate of surgery on the first page of medical records, the accuracy rate of surgery/operation coding on the first page of medical records, the accuracy rate of surgery/operation data (the number of surgeries, the number of interventional surgeries, the number of minimally invasive surgeries, the number of key surgeries, the accuracy rate of surgery/operation level), and the satisfaction of medical staff on the operation information retrieval service on the front page of medical records. Results The missing rate of surgery on the first page of medical records in the experimental group was lower than that in the control group, the accuracy rate of surgery coding and surgery/operation data on the first page of medical records in the experimental group was higher than that in the control group, and the satisfaction of medical staff on operation information retrieval in the experimental group was higher than that in the control group, with statistical significance (P<0.05). Conclusion The application of OA in medical record management can reduce the missing rate of surgery, improve the accuracy of surgery coding and surgery/operation data on the front page of medical records, improve the satisfaction of medical staff on operation related data extraction service, and provide more accurate, comprehensive and efficient operation information service for the development of hospital information, which is worthy of popularization and application.
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Received: 16 December 2020
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| ［1］冯永.病案首页疾病编码问题的原因分析及对策［J］.江苏卫生事业管理,2020,31(8):1047-1048.
［2］住院病案首页数据填写质量规范(暂行):国卫办医发〔2016〕24号［A/OL］. (2016-05-16)［2020-02-18］.http://www.nhc.gov.cn/yzygj/s2909/201606/f a8a993ec972456097a2a47379276f03.shtml.
［3］谢友勉,袁方,许学军,等.电子病历系统改造对病案首页质量的影响［J］.中国病案,2020,21(1):40-42.
［4］王丽,曾跃萍,昆瑜,等.做好疾病诊断名称与疾病分类编码对照提升病案首页质量［J］.中国病案,2019,20(4):11-13.
［5］行业动态［J］.中国护理管理,2016,16(7):862.
［6］庞涛.三级公立医院绩效考核启动,病案首页质量和电子病历水平评估被纳入考核［J］.科技新时代,2019(2):18.
［7］赵慧智,王永锋,杨利谦,等.病案首页质量分析与改进措施研究［J］.中国病案,2017,18(2):14-17.
［8］HEYWOOD N A, GILL M D, CHARLWOOD N, et al. Improving accuracy of clinical coding in surgery: Collaboration is key［J］. J Surg Res, 2016, 204(2):490-495.
［9］王怡.DRGs形势下住院病案首页信息面临的挑战和对策［J］.中华医院管理杂志,2015,31(11):831-833.
［10］郝育鹏,季新强,刘晶.逻辑校验在住院病案首页填报中的作用［J］.中国医院管理,2018,38(11):42-43. |
| [1] |
Wen Guohong. . Time and hospitalization cost analysis of cervical cancer patients first admitted to the hospital based on the front pages of inpatient medical records[J]. journal1, 2021, 28(3): 229-231. |
| [2] |
Wang Dan. . Analysis on the common indexes of the homepage data of medical records in a province under the background of performance appraisal of tertiary public hospitals[J]. journal1, 2021, 28(2): 165-167. |
| [3] |
Zhong Qianjun, Huang Liyan, Li Huixia. . Influence of admission conditions on the classification of diseases[J]. journal1, 2020, 27(6): 561-563. |
| [4] |
Liu Xinkui,Yang Linpeng,Shang Xiaoping, Dong Yichao. . Quality analysis of homepage data of inpatient cases of public tertiary hospitals in Henan Province[J]. journal1, 2020, 27(3): 272-274,279. |
| [5] |
Yang Yanmei. Effect of medical record filing management on disease diagnosis related groups and quality of the first page of medical records[J]. journal1, 2019, 26(3): 239-240. |
| [6] |
Wang Xiaoqin, Cui Xuedan. Analysis on data quality of medical record front sheet in a hospital in 2017[J]. journal1, 2018, 25(5): 351-354. |
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