DRGs付费时代下综合医院住院病案首页缺陷分析

Defects of the Front Page of Inpatient Medical Records in General Hospitals in the Era of DRGs Payment

目的基于DRGs入组因素,对黑龙江省某医院住院病案首页填写质量进行分析并提出对策,为进一步提高病案质量提供科学有效的参考。方法随机抽取黑龙江省某院2020年1月1日-2020年6月1日出院的病案首页3000份进行住院病案首页检查,按照患者信息、住院信息、诊疗信息、费用信息归类为4部分内容进行分组统计,根据原国家卫计委《住院病案首页数据填写质量规范》《住院病案首页数据质量管理与控制目标(2016版)》,基于DRGs统计缺陷项目,计算缺陷率,进行缺陷率分析。结果检索的3000份住院病案首页中,有缺陷的病案首页共计1286次;其中患者信息缺陷304次,缺陷率23.64%;住院信息缺陷735次,缺陷率57.15%;诊疗信息缺陷247处,缺陷率19.21%;费用信息缺陷0次,缺陷率0。结论病案首页中住院信息缺陷率最高,诊疗信息、患者信息缺陷率持平。从患者办理入院开始,应采用多部门共同协作,促进病案首页质量提升,确保医疗信息质量与医疗安全。

Objectives Based on DRG inclusion factors,the quality of the front page of inpatient medical records in a hospital in Heilongjiang province was analyzed and countermeasures were put forward,so as to provide scientific and effective reference for further improving the quality of medical records.Methods A total of 3000 medical records from a hospital in Heilongjiang Province from January 1st,2020 to June 1st,2020 were randomly selected to check the front page of the inpatient records.Patients’information,hospitalization information,diagnosis and treatment information,and cost information were classified into four parts for grouped statistics.According to the former National Health and Family Planning Commission"Quality Specifications for Data Fillings in the Front Page of Hospital Records"and"Quality Management and Control Objectives for Data Fillings in the Front Page of Hospital Records(2016 Edition)",the defect rate was calculated and analyzed based on DRGS statistics of defect items.Results Among the 3,000 inpatient medical records searched,the defective front pages’number of medical records was 1,286 in total.Among them,304 patients had information defects,with a defect rate of 23.64%.Inpatient information defect 735 times,defect rate 57.15%;There were 247 diagnosis and treatment information defects,with a defect rate of 19.21%.Cost information defect 0 times,defect rate 0.00%.Conclusions The absence rate of inpatient information was the highest in the first page of medical records,and the absence rate of diagnosis and treatment information and patient information was equal.Starting from the admission of patients,business personnel should take multi-department cooperation to promote the quality of the front pages of medical records and ensure the quality of medical information and medical safety.