DRG付费下的病案全流程管理模式探讨  

Application and evaluation of full management of medical record based on DRGs

作　　者：邢珺[1] 廉颖[1] 陈国强 Xing Jun;Lian Ying;Chen Guoqiang(Shandong Provincial Qianfoshan Hospital,The First Affiliated Hospital of Shandong First Medical University,Jinan 250014,Shandong Province,China;不详)

机构地区：[1]山东第一医科大学第一附属医院,山东省千佛山医院,山东省济南市250014

出　　处：《中国病案》2021年第1期38-41,共4页Chinese Medical Record

摘　　要：目的探讨DRGs付费下的病案全流程管理模式,确保病案首页的时效性和数据质量。方法病案全流程管理涉及病案管理的多个环节,通过对病案归档、终末病案质量、住院病案首页质量3个关键节点持续监管,旨在以局部带动整体。以全流程管理前的2019年1月1日-2019年6月30日为对照组,全流程管理后的半年为观察组,即2019年7月1日-2019年12月31日,对比管理前后相关指标的差异。结果通过全流程管理模式的实施,病案3日归档率达到97.4%,甲级病案率由97.2%提高至99.4%,病案首页填写完整率从35.6%提高至91.3%,主要诊断填写正确率由41.6%提高至95.4%,手术操作填写正确率由56.4%提高至96.6%。结论医院病案全流程管理模式确保了病案首页数据的时效性和数据质量,为DRGs付费的推行打下坚实的基础。Objectives To explore the full management mode of medical record based on DRG payment,and to ensnre the timeliness and data quality of The fist page of medical reeorels. Methods whole-process management involved multiple links of medical record management, such as medical record filing, quality control and coding. By optimizing the department process and rationally allocating staff, continuously supervise the three key nodes of medical record filing, the quality of terminal medical record and the quality of the front page of medical records, and compare the changes of relevant indicators before and after management. Results The 3-day filing rate of medical records was maintained at over 97.4%, and the rate of completing the front page of medical records increased from 35.62% to 91.33%. The correct rate of filling in the main diagnosis increased from 41.60% to 95.40%, and the correct rate of filling in the surgical operation increased from 56.40% to 96.60%. Conclusions The full management mode of medical records could ensure the timeliness and data quality of medical records, and lay a solid foundation for implementation of DRG payment.

关 键 词：疾病诊断相关分组 病案管理 全流程管理模式 

分 类 号：R197.323[医药卫生—卫生事业管理]