病案信息对DRGs发展的影响

The Influence of Medical Record Information on the Development of DRGs

病案首页信息和国际疾病分类ICD编码是实施DRGs的依据,其质量直接影响DRGs分组的质量和使用分组后的效果,并与付费挂钩。病案首页的管理、病案ICD编码和病案质控属于病案信息管理的内容,因此病案信息管理影响医院推行DRGs和医院的效益和管理。文章重点阐述DRGs在国外和国内的发展历程及存在的问题,国际上引入DRGs的国家和地区,都非常重视病案首页数据质量,并认为病案填报质量和编码对DRGs的分组有较大的影响,因此病案信息管理对DRGs的发展有重要影响。病案首页项目填写及时、完整、准确,主要诊断、主要手术操作选择准确,ICD编码准确,病案首页信息上传准确,加强病案质量控制,是提高DRGs分组质量的有效措施。

Home pages of medical record information and the international classification of diseases （ICD） coding is on the basis of the implementation of DRGs, andits quality directly affect packet of quality and the use of DRGs, which is linked to payment. The management of home pages of medical record, the ICD coding of the medical record and the quality control of the medical record belong to the content of the health record management, so the benefit and management of the health record management influence the DRGs and the hospital. This paper focuses on the development of DRGs in foreign and domestic situation and the existing problems, the introducing of DRGs in countries and regions, have attached great importance to the quality of medical record data, and that the information in the medical record quality and coding of DRGs grouping have greater impact, so development of health record management on DRGs have important influence. To complete the home pages of medical record timelyand accurate, select primary diagnosis and major surgical proceduresaccurately, ICD coding accuracy, upload the home pages of medical record informationaccurately, strengthen the quality control of medical record information, would be the effective measures to improve the quality of DRGs group in our country.