DRGs实施前后某院康复医疗科住院病案首页质量分析

Quality Analysis of Front Pages of Inpatient Medical Records in Rehabilitation Medical Department of a Hospital Before and After DRGs Implementation

目的探讨某院康复医疗科疾病诊断相关分组(DRGs)实施过程中住院病案首页质量。方法通过成立专项质控专家组、制定住院病案首页质控评分表、电子校验等措施建立完善质控体系,选取某院康复医疗类的住院病案,将2018年1月1日-2020年12月31日DRGs实施前设为对照组(n=600),将2021年1月1日至2023年12月31日DRGs实施后设为实验组(n=600),对两组各项信息及时性、准确性及完整性进行统计分析。结果某院康复医疗科住院病案首页实验组患者基本信息、住院过程信息、诊疗信息及费用信息漏填情况分别为3.67%、4.17%、29.00%,对照组分别为22.17%、13.17%、45.17%,实验组漏填率较对照组更低,差异有统计学意义(P<0.05);两组病案信息归档及时性差异并无统计学意义(P>0.05);实验组主要诊断选择正确率、其他诊断正确率、入组准确率及编码正确率均显著高于对照组(P<0.05);实验组样本检查准确性明显高于对照组(P<0.05);实验组样本完整性检查情况优于对照组(P<0.05)。结论DRGs入组率与住院病案首页填写质量有显著相关性,DRGs的实施可以提升住院病案首页填写的及时性、准确性和完整性。

Objective To explore the quality of front pages of inpatient medical records in the implementation of disease diagnosis related grouping(DRGs)in the rehabilitation medical department of a hospital.Methods Based on the electronic medical records information database of our hospital,the quality control system was established by setting up a special quality control expert group,developing a quality control score table on the front page of inpatient medical records,and electronic verification,and the inpatient medical records of rehabilitation medical treatment before the implementation of DRGs in our hospital at the end of 2018 to 2020 were set as the control group(n=600).The inpatient medical records of rehabilitation medical treatment after the implementation of DRGs in our hospital from 2021 to 2023 were set as the experimental group(n=600),and the timeliness,accuracy and completeness of various information in the two groups were statistically analyzed.Results The missing information of basic information,hospitalization process information,diagnosis and treatment information and cost information of patients in the experimental group were 3.67%,4.17%and 29.00%,respectively,and those in the control group were 22.17%,13.17%and 45.17%,which were significantly lower in the two groups than in the experimental group(P<0.05).There was no significant difference in the timeliness of archiving of medical records between the two groups(P>0.05).The correct rate of main diagnosis selection,other diagnosis,enrollment accuracy and coding accuracy of the experimental group were significantly higher than those of the control group(all P<0.05).The test accuracy of experimental group was significantly higher than that of control group(P<0.05).The integrity of the experimental group was better than that of the control group(P<0.05).Conclusion The enrollment rate of DRGs was significantly correlated with the quality of filling in the front page of inpatient medical records.The implementation of DRGs could improve the timeliness,accuracy and completeness of filling in the front page of inpatient medical records.The implementation of DRGs could effectively improve the quality of medical records and improve the efficiency of diagnosis and treatment.