住院病案首页信息质量控制的重要价值及对DRGs分组的影响

Important value of Quality Control of Medical record Home Page Information and its Impact on DRGs grouping

目的探究规范住院病案首页信息管理与质量控制对DRGs分组的影响。方法选择2018年1月-2018年10月的全院入组病例数69 831为研究数据,分析规范化培训前后住院病案首页信息和质量控制对DRGs分组的影响。每月随机抽取200份住院病案首页进行检查,比较月平均合格率、住院病案首页填写总错误率及类型。结果培训后月平均合格率(69.74±11.03)%显著高于培训前月平均合格率(49.83±8.75)%,差异具有统计学意义(P<0.01)。通过规范化管理和培训后,住院病案首页填写总错误率10.08%较培训前住院病案首页填写总错误率29.14%显著降低,差异具有统计学意义(P<0.01),且住院病案首页在主要诊断、其他诊断、主要手术操作、其他手术操作等四个项目的缺失情况发生率较规范培训后显著降低,差异具有统计学意义(P>0.05)。经规范化培训后对原始数据进行修正,其DRGs分组数670组显著高于原始数据DRGs分组数。结论通过规范化管理住院病案首页信息,有效地质量控制,利于DRGs平台数据的准确分组,可提高院内医疗服务质量及水平,值得推广应用。

Objective To explore the influence of standardized information management and quality control on clinical DRGs grouping.Methods Select the number of 69831 hospital-wide cases from January 2018 to October 2018 for the study data as the research data.The influence of the first page information and quality control on the DRGs group before and after standardized training was analyzed.200 home hospitalization cases were randomly selected for examination every month,and the average qualified rate,the total error rate and type of filling in the front pages of medical records were compared.Results The average pass rate after training(69.74±11.03)%was significantly higher than the average pass rate(49.83±8.75)%before training.The difference was statistically significant(P<0.01).After standardization management and training,the total error rate(10.08%)in the first page of the medical record was significantly lower than the total error rate(29.14%)in the first page of the inpatient medical record before.training.The difference was statistically significant(P<0.01),and the medical record was inpatient.After four standardized cases of major diagnosis,other diagnosis,main surgery,main operation and other items,the incidence was significantly reduced,and the difference was statistically significant(P>0.05).After standardized training,the original data were revised,and the revised DRGs grouping number was 670 groups,which was significantly higher than the original DRGs grouping number.Conclusion By standardizing the management of the first page information of medical records,effective quality control is conducive to the accurate grouping of DRGs platform data,which can improve the quality and level of hospital medical services and is worthy of promotion and application.