病案首页质量对DRG评价的影响分析  

Analysis on Influence of Quality of Homepage of Medical Records on DRG Evaluation

作　　者：钟玲 蒋沈君[1] 周小红[1] ZHONG Ling;JIANG Shen-jun;ZHOU Xiao-hong(Hangzhou Third Hospital)

机构地区：[1]杭州市第三医院

出　　处：《医院管理论坛》2021年第8期20-22,共3页Hospital Management Forum

基　　金：2019年杭州市卫生科技计划一般(A类)项目,编号:0020191075。

摘　　要：目的分析杭州市某院提升住院病案首页填写质量后对DRG评价结果的影响情况。方法利用DRG指标从医疗服务能力、医疗服务效率和医疗服务安全3个维度对杭州市某三级医院某科室2018年至2019年的出院病案数据进行综合评价,并对评价结果进行对比分析。结果通过加强病案质量管理,2019年住院病案首页填写错误率从2018年的28.29%下降到9.78%,其中主诊断填写错误率从4.14%下降到1.91%,主要手术操作填写错误率从6.62%下降到2.98%,CMI值从0.82提高到1.12,综合指数从0.59提高到1.06。首页填写错误率与综合指数呈现相关性,spearman相关系数为-0.60。结论病案首页数据的准确性和完整性对于DRG的分组具有影响,首页填写错误率越低对DRG综合评价越有利。Objective To analyze the influence of improving the quality of the homepage of inpatient medical records on the results of DRG evaluation in a hospital in Hangzhou.Methods The DRG index was used to comprehensively evaluate the discharge medical record data of a certain department of a tertiary hospital in Hangzhou from 2018 to 2019 from the three dimensions of medical service capacity,medical service efficiency and medical service safety,and compare and analyze the evaluation results.Results Through strengthening the quality management of medical records,the error rate of filling in the homepage of hospitalized medical records in 2019 decreased from 28.29% in 2018 to 9.78%,of which the error rate of filling in the main diagnosis dropped from 4.14% to 1.91%.The error rate of filling in the main surgical operation dropped from 6.62% to 2.98%.The CMI value increased from 0.82 to 1.12,and the composite index increased from 0.59 to 1.06.The error rate of filling in the homepage was correlated with the composite index,and the spearman correlation coefficient was-0.60.Conclusion The accuracy and completeness of the data on the homepage of the medical records has an impact on the grouping of DRGs.The lower the error rate of the homepage is,the better the comprehensive evaluation of DRG.

关 键 词：病案首页 疾病诊断相关分组 绩效评价 

分 类 号：R197.3[医药卫生—卫生事业管理]