病案首页填写质量规范化管理在基于疾病诊断相关分组住院绩效评价中的应用

Application of Standardized Management of Filling Quality on First Page of Medical Record in Hospitalization Performance Evaluation Based on DRG

目的:探讨病案首页填写质量规范化管理在基于疾病诊断相关分组(DRGs)住院绩效评价中的应用效果。方法:回顾性分析2020年7—12月梅州市人民医院住院病案首页数据资料6578份,分别采用CN-DRGs软件分析原始数据和填写质量规范化管理后数据,比较管理前后绩效数据指标和住院病案首页填报错误率。结果:填写质量规范化管理后主要诊断错误率、次要诊断错误率、主要手术错误率均下降。DRGs组数、总权重及病例组合指数、总分值管理后均升高,费用效率指数、时间效率指数、低风险死亡率均降低。结论:住院病案首页填写质量规范化管理可有效提高基于DRGs住院医疗绩效评价客观性,降低填报错误率。

Objective:To investigate the application effect of standardized management of filling quality on the first page of medical record on hospitalization performance evaluation based on disease diagnosis-related group(DRGs).Methods:The data information on the first page of inpatient medical records from 6578 patients in Meizhou People's Hospital from July to December 2020 were retrospectively analyzed.The original data and the data after standardized management of filling quality were analyzed by using CN-DRGs software.The performance data indicators and the error rate of filling on the first page of inpatient medical records before and after management were compared.Results:After the standardized management of filling quality,the main diagnostic error rate,the secondary diagnostic error rate,and the main surgical error rate were reduced.After the management,the DRG group number,total weight and Case Mix Index,as well as total score values were increased,while the cost efficiency index,time efficiency index,and low-risk mortality rate were reduced.Conclusion:Standardized management of filling quality on the first page of inpatient medical record can efficiently improve the objectivity of DRG-based hospitalization medical performance evaluation and reduce the error rate of filling.