摘要
目的通过比较DRG正式实施前、后一年住院病案首页质量控制改进状况,分析常见问题、改进措施和效果,为以DRG为抓手促进住院病案首页质量提升提供依据。方法抽取某三甲综合医院2021年4月1日至2023年3月31日出院的住院病案首页27130份,由2名病案科高年资专职临床质控医师和2名高年资编码员对每一份住院病案首页进行质量核查和分析。结果DRG实施后住院病案首页填报正确率(93.01%)、主要诊断正确率(93.28%)、主要诊断医师填写正确率(91.81%)、主要诊断编码正确率(94.65%)、其他手术正确率(90.42%)、其他手术医师填写正确率(90.43%)、其他手术编码正确率(92.68%),较实施前均有所提高。住院病案首页错误率(43.6%)、QY病例发生率(1.44%)、医师问题占比(0.31%)及编码问题占比(0.19%)较前一年下降。结论住院病案首页质量与DRG支付密切相关,DRG已经成为医院加强住院病案首页质量提升的重要手段,通过加强对医师和编码员的培训考核,质控体系建设和流程改进等可以显著提高住院病案首页质量。
Objectives By comparing the improvement of the quality control of the front page of inpatient medical records one year before and after the formal implementation of DRG,the common problems,improvement measures and effects were analyzed to provide a basis for promoting the quality improvement of the front page of inpatient medical records with DRG as the starting point.Methods A total of 27130 inpatient medical records were selected from a tertiary comprehensive hospital from April 1st,2021 to March 31st,2023.Two dedicated quality controllers rechecked and analyzed the front page of each medical record.Results The correct rate of the front page(93.01%),the main diagnosis(93.28%),the main diagnosis filling in by doctors(91.81%),the main diagnosis coding by coders(94.65%),the correct rate of other operation(90.43%),other operation filling by doctors(90.42%),and other operation coding by coders(92.68%)were all improved after the implementation of DRG.The error rate of the medical record front page(43.6%),the occurrence rate of QY medical records(1.44%),the proportion of doctor’s problems(0.31%),coder’s problems(0.19%)decreased compared to the previous year.Conclusions The quality of medical record front page was closely related to DRG payment.DRG had become an important means for hospitals to enhance the quality of medical record front page.By strengthening the training and assessment of doctors and coders,improving the quality control system and process,the quality of medical record front page could be significantly improved.
作者
张琳
白红颖
贾丽君
柳绪海
宋琦
马海洋
孙鹏
魏巍
陈婷
李卫红
Zhang Lin;Bai Hongying;Jia Lijun;Liu Xuhai;Song Qi;Ma Haiyang;Sun Peng;Wei Wei;Chen Ting;Li Weihong(Beijing Tongren Hospital Affiliated to Capital Medical University,Beijing 100730,China;不详)
出处
《中国病案》
2023年第10期9-12,共4页
Chinese Medical Record
关键词
住院病案首页
DRG
QY病案
质量控制
改进措施
Medical record front page
DRG
QY medical record
Quality control
Improvement measures
