北京市某三级医院神经内科住院病案首页填写质量对比分析

A Comparative Analysis on the Quality of Filling in the Front Page of Inpatient Medical Records in the Neurology Department of a Tertiary Hospital in Beijing

目的对比分析DRG背景下某医院神经内科住院病案首页填写质量,为提高数据质量提供参考。方法随机选择北京市某三级医院病案管理系统中神经内科2023年1月1日-2023年6月30日住院病案首页3060份为对照组,2023年7月1日-2023年12月31日住院病案首页3000份为观察组。某院自2023年7月开始实施病案质控方法改进,对照组采用传统病案室编码员和临床科室质控小组进行质控;观察组在对照组的基础上,联合病案管理委员会质控。根据北京市住院病案首页填写检查标准和《某院住院病案首页数据质量评分标准》,制定住院病案首页检查量表,详细记录住院病案首页书写过程中存在的缺陷数目及内容。采用卡方检验对两组评价结果进行分析,探讨住院病案首页质控的效果。结果观察组与对照组相比,住院病案首页缺项指标均有下降(P<0.05),主要诊断编码错误率由4.74%下降到3.30%、其他诊断编码错误及漏填率由6.47%下降到3.37%、主要手术操作编码错误率由3.20%下降到1.60%、其他必填项目漏填错误率由9.02%下降到5.90%,两组组间差异均具有统计学意义。DRG指标方面,DRG组数由89组增加到101组,CMI值由1.29上升至1.48,低权重占比由38.18%下降到30.14%,时间消耗指数由1.09下降到1.02,费用指数由0.98下降至0.81,低风险死亡率均为0。结论基于DRG付费方式下进行多方联动质控模式,可以提高住院病案首页数据填写质量,降低诊断和手术操作的错误率以及漏填率,进而提高住院病案首页质量。

Objectives The quality of filling in the fron page of inpatient medical records in the neurology department of a hospital under the background of DRG was compared and analyzed,thus to provide reference for improving data quality.Methods A total of 3060 inpatient medical records from January 1st,2023 to June 30th,2023 were selected as the control group,and 3000 inpatient medical records from July 1st,2023 to December 31st,2023 were selected as the observation group.The control group used traditional medical record room coders and clinical department quality control teams for quality control;On the basis of the control group,the observation group collaborates with the Medical Record Management Committee for quality control,and the quality control results are fed back layer by layer to the leaders of the responsible hospital and the Medical Record Management Department.The upper and lower levels collaborate to supervise clinical physicians in the neurology department to improve the quality of medical record writing on the front page.Both groups used the DRG system to evaluate and analyze the overall situation of hospitals in neurology in the first and second half of 2023,and to explore the effectiveness of quality control on inpatient medical records under the background of DRG.Results The missing items on the front page of inpatient medical records in the neurology department decreased in 2023(P<0.05),with the error rate of coding for major diagnostic choices decreasing from 4.74%to 3.30%,the error rate of coding for other diagnostic choices decreasing from 6.47%to 3.37%,the error rate of coding for major surgical procedures decreasing from 3.20%to 1.60%,and the error rate of missing other mandatory items decreasing from 9.02%to 5.90%.The differences between the two groups were statistically significant.In terms of DRG indicators,the number of DRG groups increased from 89 to 101,the CMI value increased from 1.29 to 1.48,the proportion of low weights decreased from 38.18%to 30.14%,the time consumption index decreased from 1.09 to 1.02,the cost index decreased from 0.98 to 0.81,and the low-risk mortality rates were all 0.Conclusions The multi-linkage quality control mode based on DRG payment could improve the data filling quality of the front page of inpatient medical records,reduce the error rate and missing filling rate of diagnosis and surgical operation,and thus improve the quality of the front page of inpatient medical records.