试行DRGs后住院病案首页督导检查方法

The Supervision and Inspection Method of the Front Pages in Hospitalization Medical Records after the Trial Implementation of DRG

DRGs是依据住院病案首页中的主要诊断、其他诊断、手术操作等数据进行的分组,DRGs分组后的病种平均住院日、平均费用等数据的准确性依赖于该地区同病种病例的数据质量。针对既往检查存在的医师填写、专家水平、数据抽样、现场检查、后期录入等方面存在的欠缺与不足,通过制定严格的管理规范;规范抽样方法,精准抽样(66.07%)和随机抽样(25.3%)相结合,并预先制定替补方案(8.63%);明确督导检查内容及责任人员,明确划分医师填写问题、编码及录入问题、信息系统传输问题的责任;增设初审、复审以及反馈确认机制。三级医院检查的9225份住院病案首页,主要诊断上报正确7685份(83.31%);临床医师主要诊断填写正确7497份(81.27%);编码员主要诊断编码正确7690份(83.36%);系统传送主要诊断正确9220份(99.95%)。基于DRG分组后的首页数据质量检查,是将DRG分组作为筛选工作,能缩小检查范围、快速聚焦疑似问题病案,既能高效查找首页数据问题,也为开展DRGs分组地区客观查找病案首页问题、提升病案首页质量提供参考。

DRGs is a kind of grouping based on and other data in the front pages of medical records. the main diagnosis, other hospital diagnosis, surgical operation The accuracy of the data included average hospitalization days, the average cost and so on depends on the data quality of the same diseases entities in this region after DRG grouping. In view of the shortcomings and deficiencies in the previous inspection, such as doctor＇s filling, expert level, data sampling, on-site inspection, and post-entry, through the establishment of strict management rules; Standard sampling method, precise sampling （66. 07%） and random sampling （25.3%）, and pre-formulation of the replacement plan （8.63%）. To clearly supervise the contents and responsibilities of the inspectors, and clearly define the responsibilities of the doctors to fill in questions, code and input questions, and information system transmission problems; Additional initial review, review and feedback confirmation mechanism. The first page of the 9225 hospitalized cases examined by tertiary hospitals, the main diagnosis was correct 7685 （83.31%）. The main diagnosis of clinical physicians was 7497 （81.27%）. The coder＇s main diagnostic code was correct 7690 （83.36%）. The main diagnostic accuracy of the system was 9220 （99.95%）. Based on the data quality inspection of front pages after the DRGs grouping, was the DRG grouping as a screening work, which could check the narrow scope, rapid focusing suspected problem records. Not only search front problems in provide the reference objectively in DRGs improvement of the oualitv of front Da^es. pages data problems effectively, but also could search grouping area, as well as provide reference for the