摘要
目的 探析应用病案室编码的病案信息技术在提升病案管理质量的效果,寻求高效的智能管理模式。方法 漯河市召陵区人民医院自2020年始落实病案室编码的病案信息技术管理,对落实前后各一年病案资料管理情况进行对比,2019年1月至2019年12月间100份病案分为对照组(常规病案管理模式),2020年1月至2020年12月间100份病案分为观察组(病案信息技术管理模式)。对两种管理模式下病案室的编码准确率、病案管理质量差异进行比较。结果 观察组病案资料的病案室编码准确率显著高于对照组,差异有统计学意义(P <0.05)。观察组病案质量管理模式评价分数显著高于对照组,差异有统计学意义(P <0.05)。结论 落实病案信息技术,有助于提升病案编码的准确率,保障病案管理质量,满足医院的发展需求,更好的为患者的健康和信息保驾护航。
Objective To explore the effect of the application of medical record information technology based on medical record room coding on improving the quality of medical record management,and to seek an efficient intelligent management mode.Methods The People's Hospital of Zhaoling District,Luohe City,implemented the management of medical record information technology based on medical record room coding from the beginning of 2020.The management of medical record data before and after implementation was compared for one year each.From January 2019 to December 2019,100 medical records were divided into a control group(conventional medical record management mode),and from January 2020 to December 2020,100 medical records were divided into an observation group(medical record information technology management mode).The coding accuracy rate of the medical record room and the difference in medical record management quality under the two management modes were compared.Results The coding accuracy rate of the medical record data in the observation group was significantly higher than that in the control group,and the difference was statistically significant(P < 0.05).The score of the medical record quality management mode evaluation in the observation group was significantly higher than that in the control group,and the difference was statistically significant(P < 0.05).Conclusion The implementation of medical record information technology helps to improve the accuracy rate of medical record coding,ensure the quality of medical record management,meet the development needs of the hospital,and better protect the health and information of patients.
作者
李永昌
王文
LI Yongchang;WANG Wen(Department of Medical Records,Zhaoling District People’s Hospital,Luohe Henan 462000,China)
出处
《临床研究》
2024年第5期183-185,共3页
Clinical Research
关键词
病案室编码
病案信息技术
病案质量
medical record room coding
medical record information technology
medical record quality
作者简介
李永昌,男,主管技师,本科。研究方向:病案信息技术相关;通讯作者:王文,副主任技师,390919411@qq.com。
