病案首页与编码质量对病种付费的影响  

The Impact of Medical Record Homepage and Coding Quality on Disease Payment

作　　者：刘成章 LIU Chengzhang(Department of Quality Control,Luoding People's Hospital,Luoding,Guangdong Province,527200 China)

机构地区：[1]罗定市人民医院质控科,广东罗定527200

出　　处：《中国卫生产业》2021年第3期82-84,共3页China Health Industry

摘　　要：目的探究病案首页与编码质量对病种付费产生的影响。方法2019年1—12月纳入研究的1056例病案首页均为该院产科、颅脑外科、普通外科、肿瘤科及心外科5个科室所收纳,依照回顾性分析方式进行平均分组,病案首页均经针对性措施解决病案首页问题,并经校对手段质控编码确认无误(试验组,n=528),重新编码前病案首页(对照组,n=528),分析两组数据差异及变化情况。结果试验组的病种付费质量包括医院数据统计分数、病案信息利用分数、疾病分组准确分数及医院经济效益分数评估均显著高于对照组,试验组中出现病案内容与病案首页不符、遗漏诊断、不完整诊断和不正确诊断的病案不良事件发生概率显著低于对照组,试验组发生漏填、错填的缺陷问题发生率显著低于对照组,组间数据差异有统计学意义(P<0.05)。结论分析病案首页质量,对影响病案首页的因素进行分析,进行针对性的改进,有利于提升病案质量,降低病案与编码质量对病种付费产生的不良影响。Objective To explore the impact of the quality of the first page of the medical record and the coding on the payment of the disease.Methods From January to December 2019 the first pages of the 1056 medical records included in the study were all accepted by the five departments of the hospital:Obstetrics,Craniocerebral Surgery,General Surgery,Oncology and Cardiac Surgery.According to retrospective analysis method,the patients were divided into groups averagely.The first page of the medical record is solved by targeted measures,and the quality control code of the proofreading method is confirmed to be correct(experimental group,n=528),and the first page of the medical record before recoding(control group,n=528),analyzed the differences and changes in the two groups of data.Results The quality of payment for disease types in the experimental group including hospital data statistics scores,medical record information utilization scores,disease grouping accuracy scores,and hospital economic benefit score evaluations were significantly higher than those in the control group.The content of medical records in the experimental group did not match the medical record homepage,and the diagnosis was omitted.The incidence of adverse events of incomplete diagnosis and incorrect diagnosis of medical records was significantly lower than that of the control group.The incidence of missing and incorrectly filled defects in the test group was significantly lower than that of the control group.The data difference between the groups was statistically significant(P<0.05).Conclusion Analyze the quality of the medical record homepage,analyze the factors that affect the medical record homepage,and make targeted improvements,which will help improve the quality of medical records and reduce the adverse effects of the quality of medical records and coding on disease payment.

关 键 词：病案首页 编码质量 病种付费 不安全事件 缺陷问题 

分 类 号：R19[医药卫生—卫生事业管理]