DRG付费体制助力病案首页质量控制  

DRG payment system help the first page of medical record quality control

作　　者：康娅 闫学丽 杨晓雨 彭蓉[1] KANG Ya;YAN Xueli;YANG Xiaoyu;PENG Rong(First Affiliated Hospital of Xi’an Jiaotong University,Xi’an 710061,China)

机构地区：[1]西安交通大学第一附属医院,陕西西安710061

出　　处：《现代医院》2021年第12期1883-1885,共3页Modern Hospitals

基　　金：陕西省重点研发计划项目(2019SF-025)。

摘　　要：目的探讨医保DRG付费体制下对临床科室进行病案首页质量控制培训管理模式,确保病案首页的数据质量。方法利用院内DRG模拟分组器筛选2016—2020年终末病案中的缺陷病案,质控员进入联众数字化病案浏览器,分析缺陷病案,查找缺陷病案产生的原因并寻找解决方法,再根据上述资料进行临床培训。结果通过这种管理模式,发现3 478份不能入组缺陷病案。未入组原因包括:疾病代码不符合分组标准2 945例,占84.68%;年龄错误30例,占0.86%;新生儿出生体重错误466例,占13.40%;性别错误37例,占1.06%。2 945例因疾病代码原因未入组病案中医生填写无效主诊断1 837例,占62.38%。编码技术缺陷导致主要诊断无效编码453例,占15.38%。因数据对接、映射问题不能入组655例,占22.24%。通过首页手术及操作名称分析,发现常见不规范手术名称。通过病案分析及临床培训纠正了无效主要诊断、不规范手术名称填写等缺陷。结论 DRG付费助力病案首页质量控制管理模式,确保了病案首页的数据质量。Objective To explore the training and management mode of the quality control of the first page of medical departments based on DRG payment, and to ensure the data quality of the first page of medical records. Methods Using hospital DRG grouper to analyze the defective medical records from 2016 to 2020, quality control staff entered the joint digital medical record browser, analyzed defect medical records and found out the causes of defect medical records and solutions. Then, they conducted clinical training according to the above data. Results By this management mode, the study found 3 478 medical records with defects. Reasons for non-inclusion included 2 945 cases(84.68%) were that disease codes did not meet the grouping criteria, 30 cases(0.86%) were age error, 466 cases(13.40%) were birth weight error and 37 cases(1.06%) were gender error. Among 2 945 cases who were not included due to disease code error, 1 837 cases were filled in invalid master diagnosis by doctors, accounting for 62.38%. The defect of coding technology resulted in 453 cases of invalid coding, accounting for 15.38%. 655 cases were not included in the group due to data interconnection and mapping problems, accounting for 22.24%. Through the analysis of the operation name on the first page of medical record, the study found the common non-standard operation name. Through medical record analysis and clinical training, the defects such as invalid main diagnosis, non-standard surgical name and so on were corrected in DRG enrollment. Conclusion Based on DRG payment, the first page of medical record quality control management mode ensures the data quality of first page of medical record.

关 键 词：疾病诊断相关分组 病案管理 质量控制 住院病案首页 

分 类 号：R197.323[医药卫生—卫生事业管理]