【摘要】 目的:分析病案统计管理信息系统的数据错误原因,并探讨数据质量控制在病案统计管理信息系统中的应用效果,为提高医院病案统计管理和数据质量管理水平提供借鉴和帮助。方法:对2015年1-12月本院病案统计管理信息系统的数据进行统计核查,对错误数据情况进行统计,并对错误数据的出现原因进行分析和总结。自2016年1月起,本院针对病案统计管理信息系统的数据错误情况,全面实施数据质量控制措施,比较2015年1-12月和2016年1-12月本院病案统计管理信息系统的数据错误情况和病案统计管理质量评分。结果:病案统计管理信息系统的数据错误主要分布于未归档的住院病案、未归还的借阅病案、未编码的住院病案、未归还的影像资料等资料中,错误原因主要为系统功能认知不足、质量管理意识缺乏、系统功能不完善。相比于2015年1-12月,2016年1-12月病案统计管理信息系统的数据错误总发生率明显降低(P<0.05),且2016年1-12月的住院病案首页填写错误率明显降低(P<0.05);相比于2015年1-12月,2016年1-12月的病案首页、入院记录、病程记录、出院记录、辅助检查、书写基本要求等病案统计管理质量评分均明显提高(P<0.05)。结论:病案统计管理信息系统的数据错误原因主要与系统本身因素、管理人员因素有关,针对错误原因实施数据质量控制措施,可有效减少病案统计管理信息系统的数据错误发生,有利于提高病案统计管理质量。更多还原

【Abstract】 Objective:To analyze the causes of medical records management information system data errors,and to explore the application effect of data quality control in the medical records management information system,to provide reference and help to improve the quality of hospital medical records management and data management level.Method:January to December 2015 in our hospital medical records management information system data statistical verification,statistics of the error data,and the causes of errors in data analysis and summary.Since January 2016,our hospital for medical record statistics management information system data error,the full implementation of the control measures of data quality,January to December 2015 and January to December 2016 in our hospital medical records management information system data error conditions and statistical quality management score.Result:The medical record statistics management information system mainly distributed data error in the hospital medical record archives,did not return the loan records,medical records without encoding,did not return the image data,the main reason for the errors of system function lack of knowledge,lack of awareness of quality management system,the function was not perfect.Compared to January to December 2015,January to December 2016 in our hospital medical records management information system the total data error significantly reduced the incidence of(P<0.05),and January to December medical records fill in error rate decreased significantly(P<0.05).Compared with January to December 2015,January to December 2016 of medical records,hospital records,medical records,hospital records,auxiliary examination,writing the basic requirements of medical records management quality score were significantly increase(P<0.05).Conclusion:The causes of medical records management information system data error mainly with the system itself factors,related management factors,the implementation of data quality for the wrong reasons needle.The quantity control measures can effectively reduce the data error of the medical record statistical management information system,and is helpful to improve the quality of medical record statistical management.更多还原