住院病案首页质量考评平台的设计与应用

Design and Application of the Quality Evaluation Platform for Home Page of Inpatient Medical Records

目的对通过网络直报报送的四川省住院病案首页进行系统质量控制,提高病案首页数据质量。方法基于DRGs分析过程中发现的住院病案首页数据质量问题,针对指标优化质控规则,根据行政管理要求和医疗机构改进需求进行平台功能设计,同时对病案质量从指标完整性、报送情况、合理性和疾病编码准确性等方面进行整体评分。结果改进后的病案质量考评平台可以对每一份住院病案首页进行质量评价并打分,通过两年实践,相关医疗机构上报率从95.02%上升到99.39%;评分从78.59分提至91.42分。结论基于DRGs的住院病案首页质量考评平台,规范了病案指标的填报,提高了病案质量,有助于病案信息的及时上报,为DRGs付费制度的展开奠定基础。

Objective To carry out systematic quality control on the home page of medical records directly reported through the network of Sichuan province,to improve the data quality of the home page of medical records.Methods According to the data quality problems on the home page of medical records found in the process of DRGs analysis,in view of the index to optimize the quality control rules,platform functionwas designed based on the requirements of the administrative and the medical institutions improvement.Furthermore,the quality of medical records was assessed for the overall score from the index of integrity,submitting status,rationality and the accuracy of diseases coding.Results The improved medical record quality evaluation platform could evaluate and score the quality of the home page of each inpatient medical record.After two years of practice,the reporting rate of relevant medical institutions increased from 95.02% to 99.39% with the score raising from 78.59 to 91.42.Conclusion The quality evaluation platform on the home page of inpatient medical records based on DRGs standardizes the filling of medical records indicators,improves the quality of medical records,facilitates the timely reporting of medical records information,and lays a foundation for the development of DRGs payment system.