CAJ | 학술논문

目的：规范病案首页填写，提高HQMS网络直报的准确性。方法利用上CMIS软件和HQMS自带的审核功能，回顾性地分析某三甲医院2013年7月-2014年12月所有病案首页的日报错误。结果80221份病案首页中，81783份上报成功，达到A级接口标准。1562份病案首页出现报错，所占比例依次为病案首页基本情况漏填（36.17%）、出院诊断填写错误（27.66%）、病案首页重复入库的病案（22.15%），病案首页逻辑性信息错（11.72%）。结论医务部应加强医师、编码员、HQMS网络直报员的监督和培训，建立院科两级质量监管体系，从数据产生的源头和终末阶段提高HQMS上报的准确性。
목적：규범병안수혈전사，제고HQMS망락직보적준학성。방법이용상CMIS연건화HQMS자대적심핵공능，회고성지분석모삼갑의원2013년7월-2014년12월소유병안수혈적일보착오。결과80221빈병안수혈중，81783빈상보성공，체도A급접구표준。1562빈병안수혈출현보착，소점비례의차위병안수혈기본정황루전（36.17%）、출원진단전사착오（27.66%）、병안수혈중복입고적병안（22.15%），병안수혈라집성신식착（11.72%）。결론의무부응가강의사、편마원、HQMS망락직보원적감독화배훈，건립원과량급질량감관체계，종수거산생적원두화종말계단제고HQMS상보적준학성。
Objective To standardize the front sheet of medical records fill in, improve the accuracy of the HQMS direct network reports. Methods The Daily report errors in the front sheet of medical records were analyzed retrospectively from July, 2013 to December 2014 in a grade 3 and first-class hospital by Using the CMIS software and HQMSauditing.Results There were 80221 front sheets of medical records, 81783 reported successes, had achieved A level. 1562 Appeared errors: basic information not filling(36.17%), discharge diagnoses fill in error (27.66%), repeated storage(22.15%), and logic information fault(11.72%).Conclusion Medical department should strengthen the supervision and training of the physicians, coders, HQMS network direct report staffs. Establish quality supervision system between hospital and departments; improve the accuracy of the HQMS reports from the data source and terminal stage.