住院病案首页信息是医疗数据统计的重要来源,是制订医疗计划、评价医疗服务质量等的重要依据,更是DRGs评价的直接数据源。为了解我国民营医院当前住院病案首页填报的质量,本报告对2016年和2017年连续上报住院病案首页数据的民营医院进行数据质量评价。2017年上报数据的民营医院共187家,分布在25个省、市、自治区,上报住院病案首页数据1867380份。对比2016年数据可见,2017年整体住院病案首页填报质量略有提高,但与公立医院比较尚有较大差距。DRG全面推广后,住院病案首页数据质量将直接影响民营医院的生存与发展。因此,民营医院亟待加强住院病案首页数据的质控,通过有效的系统工具,切实提高住院病案首页数据质量。
<<Information of in-patient medical record front sheet is an important source of medical data statistics,an important basis for making medical plans and evaluating quality of medical services,and it is also a direct data source for DRGs evaluation. In order to learn current quality conditions of in-patient medical record front sheet in Chinese private hospitals,this report evaluated data quality in private hospitals that have continuously reported in-patient medical record front sheet data from 2016 to 2017. In 2017,187 private hospitals,which are included in 25 provinces,municipalities or autonomous regions,reported 1,867,380 copies of in-patient medical record front sheet data. Compared with the data in 2016,quality of in-patient medical record front sheet data has slightly improved overall in 2017,but there is still a big gap compared with the data in public hospitals. After the popularization of DRG,quality of in-patient medical record front sheet will directly affect the survival and development of private hospitals. Therefore,it is urgent for private hospitals to strengthen quality control of in-patient medical record front sheet and improve quality of in-patient medical record front sheet through effective systems and tools.
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