基于住院病案首页数据的心血管临床专科评估框架构建

摘要

Objective Based on the key clinical evaluation program of former Ministry of Public Health,to establish an evaluation framework of cardiovascular clinical specialty,which is based on the first page of inpatient record.Methods Under the three evaluation dimensions,selecting evaluation indicators for cardiovascular clinical specialty according to the Medical Quality Management and Control Indicators of General Hospitals (2011) published by former Ministry of Public Health and clinical indicators used by main international organizations,and combining with the characteristics of cardiovascular clinical specialty and data elements of the first page of inpatient record,and establishing an evaluation framework by the Nominal Group Technique.Results The spectrum of diseases of cardiovascular clinical specialty is determined.The spectrum of surgeries and procedures of cardiovascular clinical specialty are confirmed.An evaluation framework of cardiovascular clinical specialty,including 3 first class indicators,10 second class indicators and 20 third class indicators,are established.Conclusion Establishing an evaluation framework of cardiovascular clinical specialty by the hospitalization summary reports is viable and objective.%目的 在原卫生部确定的重点临床专科评价方案的基础上,构建基于住院病案首页数据的心血管临床专科评估框架.方法 在3个评价维度下,依据原卫生部《三级综合医院医疗质量管理与控制指标(2011年版)》,参考国内外心血管临床专科评估方法和评价指标,结合心血管临床专科特点和住院病案首页实际数据情况,运用名义群体法确定评估框架.结果 确定心血管临床专科疾病谱和手术/操作谱,确定心血管临床专科重点疾病和重点手术/操作,建立心血管临床专科评估框架,其中一级指标3个,二级指标10个,三级指标20个.结论 基于住院病案首页数据建立心血管临床专科评估框架是可行、客观的.