DRGs付费方式下军队医院病案首页改进  

Progress of Front Page of Medical Records under DRGs Payment System

作　　者：但秀娟[1] 王晓京[1] 张立佳[1] 张瑶[2] 冷金昌[2] 

机构地区：[1]解放军总医院第一附属医院卫生经济管理科,北京100048 [2]解放军总医院第一附属医院信息科,北京100048

出　　处：《解放军医院管理杂志》2016年第4期323-324,344,共3页Hospital Administration Journal of Chinese People's Liberation Army

基　　金：军队"十二五"后勤科研计划项目(CWS11R297)

摘　　要：目的改进军队医院病案首页,使之与地方医保信息系统全面对接,成为DRGs付费精准的报账单。方法始终以新版国际疾病分类(ICD-10和ICD-9-CM3)为标准,以信息化为支撑,完善首页格式,规范填写内容,提供准确客观的DRGs分组信息。结果改进后病案首页提供标准化的、通用的、可编码的病案信息,使得病案上传率达100%,入组率达95%以上,实现临床数据与DRGs付费的有效对接。结论有效提高病案首页的效能,使军队医院实行DRGs付费成为可能。Objective The article aimed to improve the quality of medical records in military hospitals to make it in accordance with the local medical insurance information system and offer precise bills for the DRGs payments. Methods Using the new version of the International Classification of Diseases（ ICD- 10 and ICD- 9-CM3） as the standard,supporting by the information technology,the front page of medical records and other contents were completed,thus providing accurate and objective information for DRGs grouping. Results The improved front page of medical records provides a standardized,generic,encodable medical records information so that the uploading rate of medical records is up to 100%,the grouping rate is over 95%,interfacing of clinical data with DRGs payment is achieved. Conclusion Effect of the medical records is greatly improved,and makes it possible to implement charging by DRGs payment in the military hospitals.

关 键 词：病案首页 DRGs付费 军队医院 

分 类 号：R197.32[医药卫生—卫生事业管理]