DRG病案管理系统病案首页数据质量现状调查、影响因素及优化建议  

Investigation on Current Status,Influencing Factors and Optimization Suggestions of Medical Record Homepage Data Quality of DRG Medical Record Management System

作　　者：刘梅 朱嘉辉 LIU Mei;ZHU Jia-hui(Xuchang Central Hospital,Henan Xuchang 461000)

机构地区：[1]许昌市中心医院,河南许昌461000

出　　处：《深圳中西医结合杂志》2023年第3期130-133,共4页Shenzhen Journal of Integrated Traditional Chinese and Western Medicine

摘　　要：目的:分析许昌市中心医院疾病诊断相关分组(DRG)病案管理系统病案首页数据质量现状、影响因素及优化建议。方法:通过病案质控平台收集许昌市中心医院2021年6月至2021年12月期间的44184份病案首页数据,根据病案首页数据是否填写合格将病案分为合格组40207份和不合格组3977份,分析病案首页数据质量的影响因素并给出优化建议。结果:44184份病案病案资料中共包含2960328项应填项目,其中患者基本信息、手术信息、其他信息填错率较高,医师信息、费用信息填错率较低;对影响病案首页数据质量的影响因素进行单因素分析,工作时间、首页填写培训、首页重要性认知、首页填写质控影响病案首页数据质量。多因素logistic回归分析显示,工作时间、首页填写培训、首页重要性认知、首页填写质控是影响病案首页填写质量的因素(P<0.05)。结论:许昌市中心医院医院DRG病案管理系统病案首页数据质量仍有待进一步提高,这需要从提升临床医师专业素质、加强网络信息化建设、健全医院病案审核制度等多方面进行努力。Objective To analyze the current status,influencing factors and optimization suggestions of medical record homepage data quality of diagnosis related groups(DRG)medical record management system in Xuchang Central Hospital.Methods Through the medical records quality control platform,we collected the first page data of 44184 medical records of Xuchang Central Hospital from June 2021 to December 2021.According to whether the medical records were qualified,the medical records were divided into qualified groups 40207 and unqualified groups 3977.The influencing factors of the data quality of the medical records first page were analyzed and suggestions for optimization were given.Results Among the 44184 medical records,2960328 items should be filled in,among which the error rate of basic patient information,surgical information and other information was higher,while the error rate of physician information and cost information was lower.Single factor analysis was carried out on the factors affecting the data quality of the first page of medical records.Working time,training of the first page filling,recognition of the importance of the first page filling and quality control of the first page filling affected the data quality of the first page of medical records.Multivariate logistic regression analysis showed that working time,homepage filling training,homepage importance cognition and homepage filling quality control were the factors affecting the quality of medical records homepage filling(P<0.05).Conclusion In Xuchang Central Hospital,the data quality of the first page of medical records in DRG medical records management system still needs to be further improved,which requires efforts from improving the professional quality of clinicians,strengthening the construction of network information,and improving the examination system of hospital medical records.

关 键 词：疾病诊断相关分组 病案管理 病案首页数据 数据质量 

分 类 号：R197.324[医药卫生—卫生事业管理]