【摘要】 目的 综合评价河南省15家三级综合医院病案管理质量，为提升病案管理水平提供建议。方法 选取河南省病案质量控制平台2023年1月1日—2023年12月31日20家三级综合公立医院27项指标数据，利用熵权TOPSIS法对筛选后的15家三级综合医院病案管理质量控制指标赋予权重并对CI值进行综合排序，结合RSR秩和比法对结果分类分档。结果 主要手术编码正确率（0.085）和主要诊断编码正确率（0.076）指标权重排在前2，病案编码人员月均负担出院患者病案数（0.021）、恶性肿瘤化学治疗记录符合率（0.020）和入院记录24小时内完成率（0.020）指标权重排在后3;CI值最高的医院D5(0.843)与CI值最低的医院D9(0.401)，其CI差值为0.442；从分档结果来看，第1档包括2家医院，第2档包括10家医院；第3档包括3家医院。结论 河南省三级综合医院总体病案管理质量较好，但不同医院之间存在较大差异；编码正确率是影响病案管理质量水平的主要因素，要重视编码正确率提升工作。更多还原

【Abstract】 Objectives This study aims to comprehensively evaluate the medical record management quality of 15 tertiary general hospitals in Henan Province and provide recommendations for improving the management level. Methods Data from 27 indicators across 20 tertiary comprehensive public hospitals in Henan Province, covering the period from January 1 to December 31, 2023, were selected.The Entropy Weight TOPSIS method was used to assign weights to the case management quality control indicators of medical record management for 15 tertiary general hospitals, and the CI values were ranked. The RSR ranking and ratio method were applied to classify the results into tiers. Results The entropy values showed that the correct coding rate for major surgeries(0.085) and the correct coding rate for major diagnoses(0.076) had the highest weights, while the average monthly workload of medical record coders for discharges(0.021), the compliance rate of chemotherapy records for malignant tumors(0.020), and the completion rate of admission records within 24 hours(0.020) had the lowest weights. The hospital with the highest CI value was D5(0.843), and the hospital with the lowest CI value was D9(0.401), with a CI difference of 0.442. The classification results showed that the first tier included two hospitals, the second tier included ten hospitals, and the third tier included three hospitals. Conclusions The overall medical record management quality in tertiary general hospitals in Henan Province is relatively good, but there are significant differences between hospitals. The accuracy of coding is the main factor affecting the level of medical record management quality, and efforts should be made to improve coding accuracy.更多还原