单病种付费病案的质量管理  

Quality Management of Medical Records with Single-disease Payment and Settlement

作　　者：郭丛蓉[1] 李平[1] 梁丽[1] 马桂芹[1] 高阳[1] 郭萍[1] 

机构地区：[1]华北石油管理局总医院,任丘市062552

出　　处：《中国病案》2012年第10期17-18,共2页Chinese Medical Record

摘　　要：医疗保险机构实施单病种付费结算方式,病案成为单病种准入和医疗保险机构支付医院费用的重要依据,也关系到对实施单病种结算科室的考核评价。通过对单病种结算病案的审核,发现病案中存在诊断缺陷、病程记录中对病情分析、治疗等记录的不完整性,不能充分反映医疗诊治的过程。因此,医院需要不断加强病案书写质量的提高,这不仅是医疗质量和医疗安全的体现,也是医保部门监督审核医疗费用的客观依据。Since the adoption of single-disease-based payment and settlement in medical insurance establishments, medical records have taken as the important basis for the admittance of single disease and the payment of medical insurance establishments to hospitals. And it is also concerned with the assessment on the departments related with single disease settlement. After examination and verification of the medical records which are settled on single disease, it is found out that the course of medical diagnosis and treatment can＇t be fully reflected as there are problems such as defective diagno- sis, incomplete case analysis and treatment records in the medical records. Therefore, it is necessary to improve the handwriting of medical records. It not only reflects the quality and security of medical treatment, but also acts as the objective basis for medical insurance departments to supervise and ver- ity the medical charge.

关 键 词：医疗保险 单病种 病案质量 

分 类 号：R197.3[医药卫生—卫生事业管理]