基于疾病诊断相关组的病案首页质量管理体系研究

Research on the Quality Management System on the Home Page of Medical Records Based on Diagnosis Related Groups

目的本研究拟提出一套符合疾病诊断相关组(DRG)的病案首页质量管理体系。方法建立病案首页质控中心,组建由院科两级质控员组成的无差别专家检查团,修订完善病案首页质量评价评分表。结果研究体系的建立对基于DRG的病案首页质量有着较好的结果,其中对DRG有明显影响A类错误和B类错误均有改善(P<0.05)。结论该研究提出的病案首页质量管理体系符合DRG的管理需要,为日后病案管理的研究提供了参考依据。

Objective In this study, to propose a set of quality management system for the first page of medical records in accordance with the related group of disease diagnosis （DRG）. Methods The quality control center of the first page of the medical record was set up, and an indistinction expert inspection group composed of two level quality control members was set up to revise and improve the quality evaluation score sheet of the home page. Results The establishment of the research system had a good result for the quality of the front page of medical records based on DRG, which had a significant effect on DRG, and the improvement of class A and B errors was improved （P 〈 0.05）. Conclusion The medical record quality management system to meet the needs of the study proposed the management of DRG, for the day after the study of medical record management provides reference.