摘要
目的分析疾病诊断相关分组(DRGs)付费试点城市攀枝花市某医院DRGs付费制度病案首页质控的应用效果,并分析存在问题的主要原因及进一步改进措施。方法收集2018年10月1日至2019年9月30日DRGs付费制度病案首页质控实施前病案号尾号为3、6的住院病案14882例,对应收集2019年10月1日至2020年9月30日DRGs付费制度病案首页质控实施后病案号尾号为3、6的住院病案18677例,分析该院建立完善住院病案首页质控制度前后的变化。结果DRGs付费制度病案首页质控实施后,各项信息缺项率均高于质控前,差异有统计学意义(P<0.01)。DRGs付费制度病案首页质控实施后,主要诊断填写正确率、其他诊断填写正确率、主要手术操作填写正确率、其他手术操作填写正确率、主要诊断编码正确率、其他诊断编码正确率、主要手术操作编码正确率、其他手术操作编码正确率均较质控前提高,差异有统计学意义(P<0.01)。结论以DRGs付费制度为基础对病案首页进行质量控制,有利于提高病案首页填写的完整性、准确性,推进DRGs的进一步实施。
Objective To analyze the application effect of medical record home page quality control during the implementation of diagnosis related groups(DRGs)payment system in a hospital in Panzhihua,a pilot city of DRGs payment,and analyze the main causes for the existing problems and further improvement measures.Methods A total 14882 inpatient medical records with tail numbers of 3 and 6 before the implementation of home page quality control for DRGs payment system from October 1,2018 to September 30,2019 were collected,and the other 18677 inpatient medical records with tail numbers of 3 and 6 after the implementation of home page quality control for DRGs payment system from October 1,2019 to September 30,2020 were collected,as well.The various changes before and after the establishment and improvement of the medical record home page quality control system were analyzed.Results The information missing rate after the implemention of medical record home page quality control for DRGs payment system was higher than that before quality control,and the difference was statistically significant(P<0.01).After the implemention of medical record home page quality control for DRGs payment system,the correct rates of filling in the main diagnosis and other diagnosis,the correct rates of filling in the main surgical procedures and other surgical procedures,the correct rates of coding main diagnosis and other diagnosis,and the correct rates of coding main surgical procedures and other surgical procedures were all higher than those before quality control,and the differences were statistically significant(P<0.01).Conclusion Based on the DRGs payment system,the medical record home page quality control is beneficial to improve the completeness and accuracy of filling in the home page of medical records,and promote the further implementation of DRGs.
作者
成卓
明捷
肖俊杰
郭光会
CHENG Zhuo;MING Jie;XIAO Junjie;GUO Guanghui(Department of medical record statistics,Panzhihua Central Hospital,PanzhihuaSichuan Province,617067,China)
出处
《重庆医学》
CAS
2022年第20期3587-3590,共4页
Chongqing medicine
基金
2020年四川省卫生信息学会项目(202002)。
关键词
疾病诊断相关分组
病案首页
质量控制
应用效果
改进措施
diagnosis related groups
medical record home page
quality control
application effect
improvement measures
