陈阳

【摘要】 为了提高住院病案首页数据质量，促进精细化、信息化管理，为医院、专科评价和付费方式改革提供客观、准确、高质量数据，提高医疗质量，保障医疗安全，近几年来国家卫计委非常重视住院病案首页的填写质量，住院病案首页填写相关要求也已经成为三甲医院评审48个核心条款之一[1]。医院的病案首页属于患者整个住院情况的浓缩，主要包括：（1）患者基本情况；（2）患者的医疗情况特别是诊断情况；（3）患者的住院医疗费用的主要情况。病案首页信息数据的录入是否全面及正确影响医院的医疗信息的可靠性以及准确性，所以医院首页数据质量管理是重中之重。本文通过抽取医院近1年的病案来观察病案首页录入信息所存在的问题，并提出相应的改进措施。

【关键词】 病案首页； 数据质量管理； 持续改进

【Abstract】 In order to improve the data quality of the first page of the hospital medical record，to promote refinement and information management，to provide objective，accurate and high quality data for the hospitals，specialized evaluation and the reform of the payment method，to improve the quality of medical treatment and ensure the medical security.In recent years，the State Health and Family Planning Commission has attached great importance to the quality of filling out the first page of the hospital medical records，and the relevant requirements for the first page of the hospital medical record have become one of the 48 core clauses in the evaluation of 3 armour hospital.The first page of the hospitals medical record belongs to the concentration of the patients whole hospital condition，mainly including ：（1）the basic situation of the patient；（2）the patients medical condition，especially the diagnosis；（3）the main medical expenses of the patients.Whether the input of the first page information data of the medical record is comprehensive and correct affects the reliability and accuracy of the hospitals medical information，so the quality management of the hospital first page data is the most important.In this paper，the problems existing in the entry information of the first page of medical records are observed by taking the medical records of the hospital for nearly one year，and the corresponding improvement measures are put forward.

【Key words】 First page of the medical record； Data quality management； Continuous improvement.

First-authors address：Lianjiang Peoples Hospital，Lianjiang 524400，China

doi：10.3969/j.issn.1674-4985.2018.22.036

醫院的住院病案首页浓缩了患者的各种住院信息，病案首页填写的完整与真实性决定了病案的整体质量，也决定了整个医院的医疗信息质量，也体现了医疗机构病案管理水平，更是患者各种医疗付费方式的依据[2-3]。病案首页填写的质量要达到一定水平，确实保障准确性和规范性，不仅能够体现医院的管理水平，同时也能够侧面反映医院的诊疗水平。新医改以来，我国十分重视推动改革医疗支付工作，提高支付的便捷性，因此病案首页的质量将对支付改革起到明显影响，并和医院的绩效相挂钩。为进一步提高病案首页填写质量，有力推动新医保付费政策改革，本文将简要探讨持续改进病案首页质量存在的问题和措施，以供参考。……