DRG支付背景下病案首页诊疗信息改进效果分析

Analysis of the Effect of Improvement of Diagnosis and Treatment Information on the Case Home Page in the Context of DRG Payment

目的通过比较疾病诊断相关分组(Diagnosis Related Groups,DRG)付费前后一年病案首页诊疗信息质量,探讨采取干预措施成效,为提升病案首页质量提供经验。方法随机抽取郴州市第一人民医院DRG实施前一年(2019年6月—2020年5月)仅采取常规培训的92位医师和14位编码员完成编码的2300份患者病案作为对照组,DRG实施后一年(2021年6月—2022年5月)经过对临床医师强化培训、提高编码员的专业能力、加强三级质控体系管理、建立奖惩制度措施后92位医师和14位编码员完成编码的2300份患者病案作为研究组。检查医师填写和编码员编码的病案首页疾病和手术及操作情况。结果干预后,医师填写的主要诊断正确率、主要手术及操作正确率等和编码员编码的主要诊断编码正确率、主要手术及操作编码正确率等均较干预前提高,差异有统计学意义(P均<0.05)。结论通过对临床医师强化培训、提高编码员的专业能力、加强三级质控体系管理、建立奖惩制度措施,可以有效提高医师填写的病案首页诊疗信息质量和编码员的编码准确率。

Objective To compare the quality of diagnosis and treatment information on the case home page before and after the payment of diagnosis related groups(DRG),and to explore the effectiveness of the interventions taken to improve the quality of the case home page.Methods A total of 2300 patient medical records coded by 92 physicians and 14 coders who only received routine training in Chenzhou First People's Hospital one year before the DRG implementation(from June 2019 to May 2020)were randomly selected as the control group.One year after the implementation of DRG(from June 2021 to May 2022),after intensive training of clinicians,improvement of professional ability of coders,strengthening management of three-level quality control system,and establishment of reward and punishment system,92 physicians and 14 coders completed 2300 patient medical records as the study group.the diseases and procedures and procedures on the first page of medical records filled out by physicians and coded by coders were checked.Results After intervention,the correct rates of major diagnosis,major surgery and operation filled in by doctors and the correct rates of major diagnosis code,major surgery and operation code coded by coders were improved compared with those before intervention,and the differences were statistically significant(all P<0.05).Conclusion Through intensive training for clinicians,improving the professional competence of coders,strengthening the management of the three-level quality control system,and establishing a system of rewards and penalties,the quality of diagnostic and therapeutic information on the case home page filled out by physicians and the coding accuracy rate of coders can be effectively improved.