规范诊断书写提升DRGs数据质量

Standardize Diagnose Writing and Improving the Quality of DRGs Data

目的北京医疗保险2013年实现总额预付,DRGs分组是住院病人付费管理的重要评价工具,为了提高DRGs分组数据的上传质量,有必要规范病案首页诊断书写。方法通过加强DRGs知识宣传培训;借助信息化的手段,建立标准化的疾病诊断名称同义词数据库;利用信息化手段建立可视的诊断书写平台等方法提高诊断正确率。通过利用我院两年DRGs数据与北京市的分析对比,让医院管理人员和临床医生了解诊断填写的问题所在以及分组相关数据与北京市平均水平的差距。结果临床医生填写好诊断和病案首页的水平显著提升,2012年我院DRGs数据质量显著提高。结论达到临床医生积极参与的管理目标,提升我院DRGs数据质量。

Objective Beijing health insurance have been implemented total amount prepaid in 2013. DRGs is one of the important evaluation tool for hospital patients pay management. In order to improve the quality of DRGs data upload, it is necessary to standardize the diagnosis of the front sheet of medical record. Methods To improve the diagnostic accuracy by the ways of strengthening the DRGs knowledge publicity and training, establishing a standardized diagnosis name synonymous database by means of informatization, and using information technology means to establish visual platform for the diagnosis of writing, comparing with the data of Beijing in the past two years, let the hospital management and clinical doctors know fill in problems and the gap of the group ingrelated data between our hospital and the average level of Beijing. Results The fill in level of clinicians have significantly increased. Our hospital DRGs data quality improved significantly in 2012.Conclusions It could finally reached the goal of the clinical doctors actively participating in the management and improved DRGs data quality.