基于DRGs的病案首页质控制度的建立与效果评价
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摘要
目的建立病案首页质量控制体系,提高病案首页填写质量,为DRGs实施提供数据。方法对比质控制度建立前后1年的病案首页质量,分析住院病案首页填报完整率、病首页项目填报完整率,主要诊断选择正确率,主要手术及操作填写正确率,其他诊断填写完整正确率,病案首页数据质量优秀率,主要诊断、其他诊断、主要手术及操作编码正确率。结果检查2016年8月-2018年7月质控前出院病案共14 165份,质控后出院病案共14 937份,病案首页项目填报完整率提高了78. 71%,主要诊断选择正确率提高了27. 82%,主要手术及操作选择正确率提高了32. 18%,其他诊断填写完整正确率提高了22. 55%,主要诊断、其他诊断、主要手术及操作编码正确率提高了20.50%,病案首页质量优质率提高了56.49%,各组数据差异有显著统计学意义,尤其病案首页填写完整率、主要诊断、主要手术及操作填写正确率明显提高。结论建立病案首页质量控制体系能够有效提高病案首页填写完整性、准确性,尤其主要诊断、主要手术及操作及相关编码填写质量,有利于病案首页质量持续改进,为DRGs实施做好准备。
Objectives To establish a quality control system for the medical record homepage, improve the quality of the medical record front pages, and provide data for the implementation of DRGs. Methods By comparing the quality control system to establish the quality of the first page of the medical record one year before and after the establishment of the quality control system, analyze the completeness rate of the inpatient medical record homepage,complete the complete rate of the disease homepage project, the main diagnostic selection accuracy rate, the main surgery and operation fill in the correct rate, other diagnoses were completed correct rate, the excellent rate of data quality on the front pages of the medical records, the main diagnostic, other diagnosis, the main surgery and the correct rate of operation coding. Results From August 2016 to July 2018, A total of 14, 165 medical records were detected before the quality control, and a total of 14, 937 medical records were discharged after the quality control.The complete rate of the report on the front page of the medical record was increased by 78. 71%, and the correct rate of diagnosis was improved by 27. 82%. The accuracy of the main operation and operation selection was improved. 32. 18%, the accuracy of other diagnoses completed and improved by 22. 55%, the main diagnostic,other diagnosis, the main surgery and operation code correct rate increased by 20. 50%, the quality of the medical record home page quality rate increased by 56. 49%. The differences in data between the groups were statistically significant. In particular, the complete rate of the front pages of the medical record, the main diagnosis, and the correct rate of major surgery and operation were significantly improved. Conclusions Establishing the quality control system of the medical record front pages could effectively improve the completeness and accuracy of the medical record front pages, especially the main diagnosis, main surgery and operation and the relevant code filling quality,which was conducive to the continuous improvement of the quality of the medical record front pages and prepare for the implementation of DRGs.
Objectives To establish a quality control system for the medical record homepage, improve the quality of the medical record front pages, and provide data for the implementation of DRGs. Methods By comparing the quality control system to establish the quality of the first page of the medical record one year before and after the establishment of the quality control system, analyze the completeness rate of the inpatient medical record homepage,complete the complete rate of the disease homepage project, the main diagnostic selection accuracy rate, the main surgery and operation fill in the correct rate, other diagnoses were completed correct rate, the excellent rate of data quality on the front pages of the medical records, the main diagnostic, other diagnosis, the main surgery and the correct rate of operation coding. Results From August 2016 to July 2018, A total of 14, 165 medical records were detected before the quality control, and a total of 14, 937 medical records were discharged after the quality control.The complete rate of the report on the front page of the medical record was increased by 78. 71%, and the correct rate of diagnosis was improved by 27. 82%. The accuracy of the main operation and operation selection was improved. 32. 18%, the accuracy of other diagnoses completed and improved by 22. 55%, the main diagnostic,other diagnosis, the main surgery and operation code correct rate increased by 20. 50%, the quality of the medical record home page quality rate increased by 56. 49%. The differences in data between the groups were statistically significant. In particular, the complete rate of the front pages of the medical record, the main diagnosis, and the correct rate of major surgery and operation were significantly improved. Conclusions Establishing the quality control system of the medical record front pages could effectively improve the completeness and accuracy of the medical record front pages, especially the main diagnosis, main surgery and operation and the relevant code filling quality,which was conducive to the continuous improvement of the quality of the medical record front pages and prepare for the implementation of DRGs.
引文
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[8]张萍,陈学涛,李军,等.病案首页质量控制系统应用效果分析[J/CD].中华肺部疾病杂志:电子版,2016,9(5):533-536.
[9]王玉廷,周小兰.病案首页质控方法的研究及效果分析[J].中国病案,2017, 18(6):23-26.
[2]俞红,帅海平.疾病相关诊断分组系统meta分析[J].中国卫生信息管理杂志,2016, 13(5):527-534.
[3]李小丹,许名东.基于2414份住院病案首页数据缺陷分析及干预前后效果评价[J].中国当代医药,2018,25(14):148-151.
[4]刘明跃,王迪,邓艳宁,等.住院病案首页对DRGs绩效评价的影响[J].中国病案,2018,19(2):37-40.
[5]王青青,张霞,王瞾,等.DRGs分组中QY病案首页内涵质量缺陷分析[J].中国病案,2018, 19(3):15-18.
[6]洪卫祥,邹伏英,祝秀红,等.住院病案首页质量控制与改进措施探讨[J].基层医学论坛,2017, 21(28):3917-3919.
[7]常欢欢,杨兴宇,于丽华,等.C-DRG病案首页管理和质量控制[J].中国医院,2018, 22(6):68-70.
[8]张萍,陈学涛,李军,等.病案首页质量控制系统应用效果分析[J/CD].中华肺部疾病杂志:电子版,2016,9(5):533-536.
[9]王玉廷,周小兰.病案首页质控方法的研究及效果分析[J].中国病案,2017, 18(6):23-26.