DRGs形势下病案首页质量控制体系的建立与应用  

Establishment and Application of Quality Control System in the Front Page of Medical Records in DRGs

作　　者：曾姝[1] 严少彪[1] 李准[1] 佘颖[1] 宋萍 

机构地区：[1]重庆医科大学附属儿童医院,重庆市400014 [2]重庆医科大学医学信息学院,重庆市400016

出　　处：《现代医院管理》2017年第6期21-24,共4页Modern Hospital Management

基　　金：重庆市科委社会民生科技创新专项(cstc2015shmszx20011);重庆医科大学医学信息学院科研课题(2015A001)

摘　　要：由于DRGs在重庆试点,病案首页信息作为DRGs的唯一数据来源,其数据质量是DRGs能否顺利实施的关键。为探讨和完善病案首页质量控制体系,制定一套本院的病案首页质量评审标准,采用电脑和人工双重质控的方式,进行病案首页质量控制。目前我院病案首页已质控项占75.47%,完全质控项占50%,对卫生计生委2016年启用的《住院病案首页数据质量评分标准》中的4类共76个评分项已全部质控。我院的病案首页质控体系已初步建立,在DRGs形势下对提高首页数据质量起到了关键性的作用。As the information on the first page of medical records is the unique data source of DRGs, the quality of data is the critical factor to ensure a smooth implementation of DRGs which is currently in pilot in Chongqing. Basing on a computer-manual double control system, an evaluation criteria for the hospital to control the quality of the first page of medical records has been estab-lished. Currently, 75. 47% of the items on the first page of medical records in our hospital are included in the quality control system and 50% of the items are under total control. All the 76 evaluation items of 4 categories in The Data Quality Score Standard of the First Page of the Inpatient Cases issued by the Ministry of Health in 2016 are included in the quality control system. The quality con-trol system of the first page of medical records has been basically established in our hospital .which is playing a key role in the im-provement of first page data quality in DRGs background.

关 键 词：病案首页 质量控制 疾病诊断相关分组 

分 类 号：R197[医药卫生—卫生事业管理]