摘要
目的探讨提高普通病案3个工作日、死亡病案7个工作日归档率,对疾病诊断相关分组(DGRs)和病案首页质量的影响。方法从某院电子病案系统分别随机导出2015年1月至12月82 770份出院病案和2017年1月至12月85 451份出院病案的签收数据,2017年1月正式实施病案归档管理措施,对实施病案归档措施前后归档率、DRGs相关指标数据进行统计分析,以及对病案首页质量进行分析。结果2015年病案及时归档率为67.46%,2017年病案及时归档率为93.59%,DRGs入组率由78.3%上升至98.4%,数据比较差异均有统计学意义(P<0.05)。病案首页缺陷率由39.49%下降到9.31%,前后比较差异有统计学意义(χ^2=20 455.24,P<0.05)。CMI值由0.83上升至1.24。结论制定有效的病案管理制度和奖惩制度是提高病案归档率的有效措施,提高了病案首页质量,对DRGs具有积极意义。
Objective To explore the measures to improve the filing rate of 3 working days of common medical records and 7 working days of death medical records,and the influence on the related grouping of disease diagnosis(DGRs)and its ability index.Methods Data of 82 770 discharged medical records from January to December 2015 and 85 451 discharged medical records from January to December 2017 were randomly derived from our hospital's electronic medical record system.The measures of medical record archiving management were formally implemented in January 2017.The archiving rate before and after the implementation of medical record archiving measures,and the data of DRGs related indicators were statistically analyzed.And the quality of the front page of medical records was analyzed.Results The timely filing rate of medical records was 67.46%in 2015,93.59%in 2017,and 78.3%in DRGs group increased to 98.4%.There was statistical significance in data comparison(P<0.05).The defect rate of the front page of medical records decreased from 39.49%to 9.31%.There was statistical significance for the comparison(χ^2=20 455.24,P<0.05).CMI increased from 0.83 to 1.24.Conclusion The establishment of effective medical record management system and reward and punishment system is an effective measure to improve the efficiency of medical record filing,improve the quality of the front page of medical records,and have a positive significance for DRGs.
作者
杨燕媚
Yang Yanmei(Huizhou People's Central Hospital,Huizhou 516000,China)
出处
《中国医院统计》
2019年第3期239-240,F0003,共3页
Chinese Journal of Hospital Statistics
