住院病案首页培训对DRGs数据的影响
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摘要
目的分析病案首页填写相关知识的培训对提高病案首页数据质量以及DRGs数据质量的影响。方法通过发放知识手册、制作幻灯进行宣讲等方法对某三甲医院所有医师在1个月内进行病案首页填写培训;将培训开始前的2017年8月1日-2017年10月31日及培训结束后2017年12月1日-2018年2月28日的医院DRGs相关指标数据进行对比,分析培训前后数据质量的变化情况。结果医院DRGs入组病例数、CMI值、DRGs组数、总权重等在培训后与培训前相比,均有不同幅度提高,其中入组病例数提高6.90%,CMI值提高2.13%,DRGs组数提高1.65%,总权重提高10.43%;所有专业的CMI值与培训前相比均有不同程度提高,其中重症医学专业提高程度最大,为9.77%,其次为心血管病专业6.85%和急疹专业6.80%;入组病例数增长率最高的是重症医学专业,为25.25%;DRGs组数增长率最高的是心血管病专业,为40.15%,总权重数增长率最高的是重症医学专业,为37.65%。结论进行病案首页填写的培训对于提高病案首页数据质量、DRGs数据质量是一种行之有效的方法,应纳入常规工作,长期坚持。
Objectives To analyze the influence of training for writing skills on the quality of data in medical records' front pages and DRGs. Method According to the official documents, pamphlets and PPT about writing skills on homepages were made to training the doctors in one month, and all the DRGs data before and after and training were collected and analyzed. Results All the DRGs data of the whole hospital(including number of recruited patients, CMI index, number of DRGs groups and the whole weight) after training increased, compared with those before the training,the increasing rates of them are 6.90%, 2.13%, 1.65% and 10.43%. The CMI index of different subjects increase in different degrees, among them, the ICU's CMI index increased the most(9.77%),after that are the cardiovascular subject's CMI index(6.85%)and the emergency medicine's CMI index(6.80%); among all the numbers of DRGs groups, the cardiovascular subject's increased the most(25.25%); and among all the who weights, the ICU's increased the most(37.65%). Conclusions Training for the writing skills was an efficient way to advance the data quality of medical records homepages and DRGs.
Objectives To analyze the influence of training for writing skills on the quality of data in medical records' front pages and DRGs. Method According to the official documents, pamphlets and PPT about writing skills on homepages were made to training the doctors in one month, and all the DRGs data before and after and training were collected and analyzed. Results All the DRGs data of the whole hospital(including number of recruited patients, CMI index, number of DRGs groups and the whole weight) after training increased, compared with those before the training,the increasing rates of them are 6.90%, 2.13%, 1.65% and 10.43%. The CMI index of different subjects increase in different degrees, among them, the ICU's CMI index increased the most(9.77%),after that are the cardiovascular subject's CMI index(6.85%)and the emergency medicine's CMI index(6.80%); among all the numbers of DRGs groups, the cardiovascular subject's increased the most(25.25%); and among all the who weights, the ICU's increased the most(37.65%). Conclusions Training for the writing skills was an efficient way to advance the data quality of medical records homepages and DRGs.
引文
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[4]卫生部办公厅.卫生部办公厅关于印发《三级综合医院评审标准实施细则(2011年版)》的通知[Z].中华人民共和国卫生部公报,2011.
[5]国家卫计委.国家卫生计生委办公厅关于印发住院病案首页数据填写质量规范(暂行)和住院病案首页数据质量管理与控制指标(2016版)的通知[Z].中华人民共和国国家卫生和计划生育委员会公报,2016.
[6]明平勇,柯珊红.基于DRGs系统应用与推广对策探讨[J].中国卫生信息管理杂志,2017,14(3):418-422.
[7]刘婕.规范诊断书写提升DRGs数据质量[J].中国病案,2014,15(3):16-17.
[2]肖晓兰,韦艳灵.病案信息对DRGs发展的影响[J].中国病案,2016,17(12):6-8,42.
[3]隗和红,卢铭,焦建军,等.诊断选择和手术操作对DRGs分组影响的分析[J].中华医院管理杂志,2015,31(11):869-871.
[4]卫生部办公厅.卫生部办公厅关于印发《三级综合医院评审标准实施细则(2011年版)》的通知[Z].中华人民共和国卫生部公报,2011.
[5]国家卫计委.国家卫生计生委办公厅关于印发住院病案首页数据填写质量规范(暂行)和住院病案首页数据质量管理与控制指标(2016版)的通知[Z].中华人民共和国国家卫生和计划生育委员会公报,2016.
[6]明平勇,柯珊红.基于DRGs系统应用与推广对策探讨[J].中国卫生信息管理杂志,2017,14(3):418-422.
[7]刘婕.规范诊断书写提升DRGs数据质量[J].中国病案,2014,15(3):16-17.