病案首页填写对DRGs数据质量的影响

The Influence of Medical Record Home Page Filling to the Data Quality in the DRGs

目的根据DRGs原始数据提取质量的影响因素分析,制定相应的管理措施,以起到促进提升病案首页数据质量的效果。方法对采集的病案首页信息中部分缺失项目及DRGs分组过程中的实际问题进行统计分析。结果数据分析显示,病案首页信息并发症漏填、重症转入转出情况不符、诊断书写不规范等情况,直接影响DRGs平台数据的提取及后期分组质量。采取改进措施后,病案首页部分项目填写缺失情况第四季度较第三季度有明显改善,其中手术级别填写缺项率降幅较大,由12.34%降低至9.26%,且通过X2统计学分析,P<0.05。结论病案首页信息填写完整、准确是影响DRGs平台数据提取质量的主要因素。通过信息平台和管理措施的干预对病案首页填写质量起到了积极作用,同时也需要在后续工作中持续改进。

Objective To formulate corresponding management measures according to the influence factors analysis on the raw data extraction quality of DRGs, promote the effect of the improvement of data quality in the medical record home page. Methods To carry out a statistical analysis on the missing items in the medical record home page and the practical problems in the process of grouping DRGs. Re- suits The data analysis shows that the situations such as missing filling of complications in medical record home page, inconsistent shift situation of severe iUness, lack of standardization of diagnosis writing directly affect the quality of DRGs platform data extraction and the late group. After the implementation of improvement measures, parts of medical record home page project filling in the missing items have been improved in the fourth quarter compared with the third quarter, in which the missing item rate of operation level filling decreased larger, which reduced from 12.34% to 9.26%, and through the X2 statistics analysis, P 〈 0.05. Conclusions The complete and accurate filling out of the medical record home page information is the main factor influencing the quality of DRGs platform data extraction. The inter- vention through platform and management measures played a positive role in improving the filling quality of the medical record home page, and need continuous improvement in the follow-up work.