基于DRGs的病案首页诊断错误原因与干预措施

Causes and Intervention Measures of Diagnostic Errors in the Front Page of Medical Records based on DRGs

目的建立病案首页质量控制体系,提高病案首页出院诊断填写质量,为DRGs实施提供高质量数据。方法对比质量控制体系建立前后6个月的病案首页出院诊断填写质量,分析病案首页主要诊断填报正确率、其他诊断填写完整正确率及其相关编码正确率。结果质控前出院病案7270份,质控后出院病案7860份,主要诊断选择正确率提高18.91%,其他诊断填写完整正确率提高27.97%,主要诊断、其他诊断编码正确率提高21.41%,各组数据差异有统计学意义。结论建立病案首页质量控制体系能够有效提高病案首页主要诊断、其他诊断及诊断编码填报质量,有利于病案首页质量持续改进,为DRGs实施做好准备。

Objective:To establish a quality control system for the home page of medical records,improve the quality of discharge diagnosis filling in the home page of medical records,and provide high-quality data for the implementation of DRGs.Method:The quality of discharge diagnosis filling in the first page of medical records six months before and after the establishment of the quality control system was compared.The accuracy of main diagnosis filling in the first page of medical records,the accuracy of other complete diagnosis filling and the accuracy of the relevant codes were analyzed.Result:There were 7,270 discharged medical records before the quality control,and 7,860 after the quality control.The accuracy of main diagnostic selection was increased by 18.91%,and the accuracy and completion of other diagnoses was increased by 27.97%.The coding accuracy of main diagnosis and other diagnosis was increased by 21.41%,and the difference between each group was statistically significant.Conclusion:Establishing quality control system of medical record home page can effectively improve the quality of main diagnosis,other diagnosis and diagnostic code filling of medical record home page,which is conducive to continuous improvement of medical record home page quality and preparation for DRGs implementation.