建立审核规则库以提升病案首页质量的实践探索

The Practice of Establishing Audit Rule Base to Improve the Quality of Medical Record Home Page

住院病案首页数据质量是医院管理的重中之重。病案首页数据不仅是各种信息生成、各类统计报表的数据源头,其相关诊断、手术操作的数据还会影响到DRGs的分组结果。为进一步提高病案首页上报准确率,满足病案管理快捷、便利、高质量的需求,医院编码员开始建立审核规则库[1]。充分发挥编码员的翻译作用,扩展翻译功能,自行建立编码与非编码审核规则库,并在每个环节自动进行完整性、逻辑性、规范性、合理性校验,控制出院病案首页质量。审核规则库的建立提高了临床医师和编码员病案首页填报的准确率,促进了病案首页填报质量的持续提高。

The home page data quality of medical record is the most important part of hospital management.And it is not only the data source of all kinds of information generation and statistical reports,but also the related diagnosis and operation data will affect the DRGs grouping results.In order to further improve the accuracy of reporting the home page of medical record and meet the needs of rapid,convenient and high quality medical record management,the coders of hospital began to set up an audit rule base.Give full play to the role of coders,expand the translation function,set up their own coding and non-coding audit rule base,and through the established audit rule base,in each link automatically carry out integrity,logic,standardization,rationality check,control out the quality of the home page of hospital medical record.The audit rule base improves the accuracy of the home page filling of clinicians and coders,and promotes the continuous improvement of the quality of home page filling of medical record.