DRGs形势下住院病案首页信息面临的问题和对策  

Problems and Countermeasures of Home Page Information of Inpatient Medical Records Under the Situation of DRGs

作　　者：王婷婷 翟坪 周颖 WANG Tingting;ZHAI Ping;ZHOU Ying(Medical Record Room,Nanjing Jiangbei Hospital,Nanjing Jiangsu 210048,China)

机构地区：[1]南京江北医院病案室,江苏南京210048

出　　处：《中国卫生标准管理》2022年第15期6-9,共4页China Health Standard Management

摘　　要：目的 为了探究DRGs形势下住院病案首页信息面临的问题和对策。方法 选取南京江北医院的4个DRGs试点科室,随机选取2020年4月—2021年7月的出院病案4 560份,进行分析,找出住院病案首页信息填报中存在的缺陷,并进一步进行统计分析病案信息填报中出现问题的类型。结果 在随机抽取的4 560份住院病案中,住院病案首页信息填写出现错误的共有2 043份,住院病案首页信息填写出错率为44.80%,常见的问题主要包括主要诊断选择错误、诊断不规范、漏报其他诊所、主要手术或操作选择错误、漏报手术或者操作不规范、国际化疾病诊断与手术编码缺乏统一性。结论 在DRGs形势下,南京江北医院的住院病案首页信息面临着数据填写错误等各方面的问题,住院患者病案首页信息填写准确率和质量有待提高,必须采取积极有效的措施来提高住院病案首页信息的填写质量。Objective To explore the problems and countermeasures of home page information of inpatient medical records under the situation of DRGs. Methods Four DRGs pilot departments of Nanjing Jiangbei Hospital were selected, and 4 560 discharge medical records from April 2020 to July 2021 were randomly selected for analysis to find out the defects in the information reporting on the homepage of inpatient medical records, and further conduct statistical analysis on the types of problems in the filling of medical record information. Results Among the 4 560 inpatient medical records randomly selected, there were 2 043 cases with errors in filling in the information on the first page of the inpatient medical records. The error rate of filling in the information on the first page of the inpatient medical records was 44.80%. The common problems mainly included errors in the selection of major diagnoses,irregular diagnoses, underreporting of other clinics, wrong selection of major surgeries or operations, underreporting surgeries or irregular operations, and lack of uniformity in international disease diagnosis and surgery coding. Conclusion Under the situation of DRGs, Nanjing Jiangbei Hospital’s inpatient medical record homepage information is faced with various problems such as data filling errors. The accuracy and quality of the inpatient medical record homepage information need to be improved. Active and effective measures must be taken to improve the quality of filling in the information on the homepage of inpatient medical records.

关 键 词：DRGS 形势 住院病案 首页信息 问题 对策 

分 类 号：R197[医药卫生—卫生事业管理]