中医病案首页中医药费用与诊疗信息填写存在的问题及整改分析

Problems and rectification analysis of filling in medicine expenses and treatment information on the first page of traditional Chinese medicine medical records

目的 针对中医病案首页中医药费用信息与诊疗信息填写逻辑性校验有误的现象,分析南京市溧水区中医院中医病案首页存在逻辑性校验错误的原因并提出整改措施。方法 按照中医病案首页填写规则,对照国家公立医院绩效接口标准,在病案管理系统中制定病案首页逻辑性校验报表,对2019年1月1日至2020年12月31日所有的出院归档病历按照治疗类别与中医药类费进行校验、使用医疗机构制剂填写与医疗机构制剂费进行校验、使用中医诊疗技术填写与中医类(中医和民族医医疗服务)进行校验规则,筛选出存在逻辑性校验问题的科室,并对各科室费用逻辑性校验有误数据进行统计。结果 2019年1月至2020年12月所有归档病历中,涉及逻辑性校验问题的为16个科室,该时间段所涉及的16个科室出院归档病历共24158份,存在逻辑性校验有误的病历5121份,占21.20%,其中治疗类别与住院费用中医药类校验有误的病历占24.51%,使用医疗机构制剂填写与医疗机构制剂费校验有误的病历占41.20%,使用中医诊疗技术填写与中医类(中医和民族医医疗服务)校验有误的病历占34.29%。结论 南京市溧水区中医院的中医病案首页住院费用对照有待提高,需要加强和医保部门、临床科室的沟通,保证住院费用对照的及时性和准确性,同时将逻辑性校验加入临床医师书写病历环节中,提高病案的书写质量,减少纸质病历的返修率。

Objective The Chinese medicine cost information,diagnosis and treatment information on traditional Chinese medicine medical record homepage appeared error in the logical verification.Based on the phenomenon,this study analyzes the causes of logical verification errors in the front page of traditional Chinese medicine medical records in Lishui Hospital of Traditional Chinese Medicine,and puts forward rectification measures.Methods According to the rules for filling out the first page of traditional Chinese medicine medical record homepage and comparing with the performance interface standards of national public hospitals,a logical verification report for the first page of medical records was developed in the medical record management system.The archived medical records were obtained from January 2019 to December 2020.Firstly,this study performed verification according to the treatment category and Chinese medicine fee.Subsequently,the medical institution preparations filling and medical institution preparations fees were used for verification.Finally,the rule of Chinese medicine diagnosis and treatment technology to formulate and Chinese medicine(Chinese medicine and ethnic medicine medical services)are applied for verification.The data statistically analyzed that the departments had logical verification problems and the cost of each department was logically verified wrong.Results Among all archived medical records from January 2019 to December 2020,16 departments involved logical verification problems.During this period,24158 medical records were filed from the 16 departments of the hospital and there were logical verification errors in 5121 medical records,accounting for 21.20%.The proportion of medical records with incorrect verifications of treatment categories and hospitalization expenses was 24.51%,41.20% of the medical records filled in with medical institutions′ preparations and verified with medical institutions′ preparation fees incorrectly. Additionally, the medical records with incorrect diagnosis and treatment technology and Chinese medicine (Chinese medicine and ethnic medicine medical services) that was checked incorrectly was also accounted for 34.29%. Conclusion The comparison of hospitalization expenses on the first page of traditional Chinese medicine medical records in Lishui District Hospital of traditional Chinese medicine needs to be improved. It is necessary to strengthen the communication with medical insurance department and clinical department to ensure the timeliness and accuracy of hospitalization expenses comparison. At the same time, logical verification is added to the link of clinicians writing medical records, so as to improve the writing quality of medical records and reduce the revise rate of paper medical records.