158家医疗机构按病种分值支付下住院病案首页的缺陷剖析

Analysis of Defects on the Front Page of Inpatient Medical Records in 158 Medical Institutions Based on Disease Score Payment

目的基于按照病种分值付费影响因素,对宿迁市158家医院住院病案首页质量进行分析并提出对策,为进一步提高宿迁市住院病案首页质量提供科学有效的参考。方法按照全部三级医院、95%二级医院及60%一级医院,且一、二、三级医院年均出院人次分别大于100、400、4500人次的原则,随机抽取宿迁市电子病历质控平台中158家医院2021年1月1日-12月31日期间出院患者共计582292份住院病案首页,平台按照住院病案首页填写规范要求自动进行质控。按照必填项、条件必填项归类为2部分内容进行质控结果统计。采用SPSS23.0对数据进行分析,计算住院病案首页完整率、上传率、平均得分、优秀率、必填项缺陷占比、条件必填项缺陷占比、编码人员工作量,并对住院病案首页平均得分t检验。结果三级医院完整率及上传率均为100%,一、二级医院在90%以上;三级医院平均得分97.93分,二级医院90.99分,一级医院87.17分,独立样本t检验有统计学意义。缺陷的住院病案首页共计453950份,占77.96%;其中必填项缺陷1371524项次,占22.03%;条件必填项缺陷4854625项次,缺陷占比77.97%;其中三级医院主要缺陷是尸检填写错误,占比是30.9%,二级医院主要缺陷是其他诊断或编码未填写,占比是68.6%,一级医院主要缺陷是未填写出院诊断或填写错误,占比是99.7%。三级医院编码员工作负担最大。结论各级医院住院病案首页填写均存在不足,三级医院住院病案首页质量相对较好,各级住院病案首页条件必填项缺陷占比最高,三级医院主要存在逻辑误区类错误,一二级医院主要存在诊断编码类错误,同时各级医院编码员配置不合理。说明各级医院需要进一步加强住院病案首页填写质量,推动住院病案首页持续改进。

Objectives This study aims to analyze the quality of the home pages of inpatient medical records in 158 hospitals in Suqian City and propose countermeasures based on the influencing factors of payment based on disease type scores,so as to provide scientific and effective reference to further improve the quality of inpatient medical record front page in Suqian City.Methods According to the principle of all tertiary hospitals,95%secondary hospitals and 60%primary hospitals,and the discharge volume of primary,secondary,and tertiary hospitals is greater than 100,400,and 4500 person-time respectively,582,292 front pages of hospitalized medical records of discharged patients from 158 hospitals in the electronic medical record quality control platform of Suqian City from January 1 to December 31,2021 were randomly selected.Automatic quality control was carried out according to the standard requirements of filling in the front page of inpatient medical records on the platform.Quality control results were classified into two parts according to mandatory and conditional items.SPSS23.0 was used to analyze the data and calculate the completion rate,upload rate,average score,excellent rate,proportion of defects in required items,proportion of defects in conditionally required items,and workload of coders on the front page of inpatient medical records.A t-test was performed on the average score of the front page of inpatient medical records.Results The completion rate and upload rate of tertiary hospitals were both 100%,and the rates of first and second-tier hospitals were over 90%.The average score of tertiary hospitals was 97.93 points,that of second-level hospitals was 90.99 points,and that of first-level hospitals was 87.17 points.The independent sample t-test was statistically significant.There were 453,950 defective front pages of hospitalization medical records,accounting for 77.96%.Among them,there were 1,371,524 required deficiencies,accounting for 22.03%.There were 4,854,625 defects in the required items,accounting for 77.97%of the defects.Among them,the main defect of the tertiary hospitals was that the autopsy was filled in incorrectly,accounting for 30.9%;the main defect of the second-level hospitals was that other diagnoses or codes were not filled in,accounting for 68.6%;the main defect of the first-level hospitals was that the discharge diagnosis was not filled in or filled in incorrectly,accounting for 99.7%.Coders in tertiary hospitals had the greatest workload.Conclusions There are deficiencies in filling out the front page of inpatient medical records in hospitals at all levels,and the quality of the first page of inpatient medical records in tertiary hospitals is relatively good.The defects of required items on the front page of inpatient medical records at all levels accounted for the highest proportion.There are mainly logical misunderstanding errors in the third-level hospitals,and there are mainly diagnostic coding errors in the first-and second-level hospitals.At the same time,the allocation of coders in hospitals at all levels is unreasonable.It shows that hospitals at all levels need to further strengthen the quality of filling in the home pages of inpatient medical records and promote continuous improvement on the home pages of inpatient medical records.