摘要
目的了解基于DRG的住院病案首页质量现状及产生质量缺陷的原因,为提高DRG管理效果提供参考。方法选取徐州市某三甲医院2021年1月1日-2021年12月31日出院的168495份住院病案,使用徐州市DRG病案质控系统进行计算机自动质控,然后人工核对。结果质控出5368份缺陷病案,整理得到5663条错误记录,其中影响DRG入组的错误3222条,占56.9%,不影响DRG入组的错误2441条,占43.1%。主要错误分布于手术信息(76.2%)、诊断信息(14.8%)、及基本信息(4.56%)。结论住院病案首页质控系统的信息化程度落后、临床医师对病案首页填写的不重视、编码员对DRG分组规则不熟悉是影响病案首页质量的主要原因。应加强病案质控系统的智能化、定期开展病案首页编码与DRG监管规则的培训、完善病案首页质控奖惩制度等措施,以提高DRG管理效果。
Objectives This study aims to understand the quality status of the front page of inpatient medical records based on DRG and the causes of quality defects and provide a reference for improving the management effect of DRG.Methods 168495 inpatient medical records discharged from a tertiary hospital in Xuzhou City from January 1,2021 to December 31,2021 were selected.The Xuzhou DRG medical record quality control system was used for automatic computer quality control,followed by manual verification.Results 5368 defective medical records were obtained through quality control,and 5663 error records were sorted out,including 3222 errors that affected DRG enrollment,accounting for 56.9%,and 2441 errors that did not affect DRG enrollment,accounting for 43.1%.The main errors were distributed in surgical information(76.2%),diagnostic information(14.8%),and basic information(4.56%).Conclusions The main reasons affecting the quality of the front page of medical records are the backward informatization of the front-page quality control system of inpatient medical records,the lack of attention paid by clinicians to filling out the front page of medical records,and the unfamiliarity of coders with DRG grouping rules.It is necessary to strengthen the intelligence of the quality control system of medical records,regularly carry out training on the coding of the front page of medical records and DRG regulatory rules,and improve the reward and punishment system for quality control of the front page of medical records,so as to improve the effect of DRG management.
作者
文娟
张翔
Wen Juan;Zhang Xiang(Department of Medical Records and Statistics,The Affiliated Hospital of Xuzhou Medical University,Xuzhou 221000,China;不详)
出处
《中国病案》
2023年第5期18-21,共4页
Chinese Medical Record
关键词
质量控制
DRG
缺陷分析
住院病案首页
Quality control
DRG
Defect analysis
Front page of medical records
