基于DRGs的住院病案首页数据质量改进实践探索

Practice of Improving the Home Page Data of Inpatient Medical Records Based on DRGs

目的研究基于DRGs的住院病案首页数据质量改进实践探索。方法随机抽取我院于2018年1~9月和2019年1~9月各1000份住院病案,对所有住院病案首页数据中存在的缺陷问题进行汇总和统计,并分析缺陷问题存在的主要原因,依据医院情况及规范制订相应的改进计划,同时开展医疗方案,观察对住院病案首页数据质量的提高程度。结果2018年住院病案首页数据总缺陷率11.56%,2019年住院病案首页数据缺陷率为3.08%,同比下降8.48%,对于2018年期间与2019年期间经质量改进措施后住院病案首页数据缺陷率差异明显(P<0.05)。结论应用持续医疗改进措施,能够提升住院病案首页数据质量,进一步为医院数据分组准确性及DRGs工作实施打造良好基础,有助于提升医院服务水平,促进医院健康可持续发展。

Objective To study the practice of improving the home page data of inpatient medical records based on DRGs.Methods One thousand cases of inpatient medical records in our hospital from January 2018 to September 2018 and to January 2019 to September 2019 were randomly selected,and the defects in the front page data of all inpatient medical records were summarized and counted.The main causes of defects were analyzed,and the corresponding improvement plan were made according to hospital conditions and specifications,the medical programs were developed.Then,the improvement of data quality on the front page of inpatient medical records were observed.Results In 2018,the total defect rate of home page data of inpatient medical records was 11.56%,and in 2019,the defect rate of home page data of inpatient medical records was 3.08%,a year-on-year decrease of 8.48%.For the data defect rate of home page of inpatient medical records after quality improvement measures in 2018 and 2019,there was significant difference(P<0.05).Conclusion The application of continuous medical improvement measures can improve the home page data of inpatient medical records,further build a good foundation for the accuracy of hospital data grouping and the implementation of DRGs,and it is help to improve the service level of the hospital,and promote the healthy and sustainable development of the hospital.