【摘要】 目的通过查找手术麻醉系统与病案首页系统中手术名称的一致性影响因素,探讨手术质量指标的数据来源及质量控制方法。方法采用全样本统计,在EXCLL中运用函数对独立的手术麻醉系统和病案首页系统进行匹配,查找手术麻醉系统和病案首页系统中手术名称一致性影响因素。结果在两系统病案号、入院日期、手术日期相同的1407例中,手术名称完全相同的有971例,一致率69.0%;如果以手术名称对应的手术代码精度评估一致性,其类目(整数)、亚目(小数点后1位数)、细目(小数点后2位数)一致率分别为84.8%、75.3%、70.6%。结论影响手术麻醉系统和病案首页系统中手术名称一致性的主观因素包括对字典库名称不熟悉、对主要手术选择原则不熟悉、工作态度不认真;客观因素包括手术麻醉系统缺术后手术名称、字典库名称不能满足临床需求。因此,利用手术麻醉系统计算手术质量指标还需要完善手术麻醉系统,优化手术字典库,加强人员培训及质量控制。更多还原

【Abstract】 Objectives The data source and quality control method of the surgical quality index were discussed by finding the consistent influencing factors of the surgical name in the surgical anesthesia system and the front page system. Methods Using full sample statistics, the function was used to match the surgical anesthesia system and the front page system in EXCLL, and the factors influencing the consistency of operation names in the surgical anesthesia system and the front page were found. Results In the 1,407 patients of two systems with the same disease case number, date of admission and date of operation in the two systems, 971 had the same name of operation, with a consistent rate of 69.0%. If a procedure name corresponding to the code accuracy assessment of consistency, the category(integer), suborder(1 decimal places), breakdown(2 digits after the decimal point) the consistent rate of 84.8%, 75.3% and 70.6% respectively. Conclusions Subjective factors influencing the consistency of surgical name in the surgical anesthesia system and the home page system is that not familiar with dictionary names, not familiar with major surgical selection principles and not serious at work. The objective factors was that the surgical anaesthesia system lacks the operative name and the dictionary names do not meet clinical needs. Therefore, it is necessary to modify the operation anesthesia system, optimize the operation dictionary database, train the personnel and control the quality of the operation when we calculate the quality of the surgery in the anesthesia system.更多还原