王凤丽

【摘 要】目的：研究分析住院病案首頁通过电子病历系统与编码员审核对于数据质量带来的影响情况。方法：选取我院在病历信息系统中调取的2020年1月至9月期间共计100例出院患者病历资料作为参照组，并调取2020年10月至2021年6月之间出院的100例患者病历资料纳入实验组。我院从2020年起，利用电子病历系统软件，审核住院病历首页信息中患者一般资料、住院情况填写完整性，编码工作者通过审核住院病历首页的一般资料填写有效性，以便及时发现问题，和临床医师进行沟通确认。交由病历科室组织专家对两组的住院病历首页数据填写质量展开审核分析。结果：实验组患者信息整体完整率达到100%（100/100），相较于参照组89.00%（89/100）明显偏高，组间对比呈（P<0.05）；实验组诊疗信息的精准率达到97.00%（97/100），相较于参照组81.00%（81/100）明显偏高，组间对比呈（P<0.05）有意义；实验组其他审核信息填写准确率98.00%（98/100），相较于参照组89.00%（89/100）明显偏高，组间对比呈（P<0.05）有意义。结论：合理运用电子病历系统的自检功能，并由编码工作者负责审核住院病历首页的数据信息完整性，能够强化信息的精准性，保障病历首页的数据质量。

【关键词】住院病案首页；电子病历系统；编码人员；数据质量

The first page of inpatient medical records is reviewed by the electronic medical record system and coders on the impact on data quality

Wang Fengli

Honghuagang People’s Hospital of Zunyi， Guizhou， Zunyi Guizhou 563000， China

【Abstract】objective： To study and analyze the influence of the first page of inpatient medical record on data quality by electronic medical record system and coder. Methods： The medical records of 100 discharged patients from January 2020 to September 2020 were collected from the medical records information system of our hospital as the reference group， the medical records of 100 patients discharged from October 2020 to June 2021 were collected and included in the experimental group.Since 2020， our hospital has used the electronic medical record system software to verify the completeness of filling in the general information of patients and their hospitalization conditions on the first page of the hospital medical records， and the validity of filling in the general information on the front page of the hospital medical records by the coder， in order to find the problem in time， and communicate with clinicians for confirmation. The Department of Medical Records to organize experts to two groups of hospital medical records home data filling quality audit analysis. Results： The complete rate of patients’information in the experimental group was 100% （100/100） ， which was significantly higher than 89%（89/100）in the reference group ，and the comparison between the groups was（P<0.05）；The accurate rate of patients’information in the experimental group was 97.00% （97/100） ， which was significantly higher than（81.00% ， 81/100）in the reference group，and the comparison between the groups was（P<0.05）；the accuracy of other information in the experimental group was 98.00% （98/100） which was significantly higher than（89.00%，89/100）in the reference group， and the intergroup comparison was significan（P<0.05）.Conclusion：The proper use of the self-examination function of the electronic medical record system and the responsibility of the coding staff to check the integrity of the data on the first page of the hospital medical record can enhance the accuracy of the information and ensure the quality of the first page of the medical record.

【Key？Words】First page of in-patient Medical Records； Electronic Medical Record System；Coding personnel； Data quality

住院病案首页作为医务工作者运用文字、符号、代码等不同方式[1]，把患者住院过程中重要信息进行综合分析在特定表格当中，从而形成患者数据摘要信息。住院病案首页的内容主要以患者一般资料、住院过程、治疗信息、费用情况为主。……