病案首页填写质量对DRGs数据分组的影响  

The Impact of Filling-out Quality of Medical Record Homepage on DRGs Data Grouping

作　　者：李晓霞[1] 孙丽[1] 陈万莉 孙璐[1] 孙艳霞 宋金燕 LI Xiao-xia;SUN Li;CHEN Wan-li;SUN Lu;SUN Yan-xia;SONG Jin-yan(Changji Branch,The First Affiliated Hospital of Xinjiang Medical University,Changji 831100,China)

机构地区：[1]新疆医科大学第一附属医院昌吉分院,新疆昌吉市831100

出　　处：《现代医院管理》2023年第6期58-60,共3页Modern Hospital Management

摘　　要：目的分析病案首页填写质量对疾病诊断相关分组(DRGs)数据分组的影响。方法调取2019年与2021年61730份出院患者病案首页及DRGs数据,质控评估病案首页填写质量,统计病案首页核心指标填写错误率并分析其与DRGs数据的相关性。结果病案首页核心指标填写错误率及总错误率两年相比差异有统计学意义(P<0.05),主要手术、操作填写错误率与病例组合指数(CMI)呈负相关(相关系数r=-0.611,P=0.002);其他诊断、编码填写错误率与DRGs总量、DRGs组数呈负相关(r=-0.649、-0.511,P=0.001、0.011);核心指标总错误率与DRGs总量呈负相关(r=-0.487,P=0.016)。结论核心指标错误填写对DRGs数据分组影响较大,加强病案首页质控,保证其准确性、完整性是提高DRGs入组率的重要前提。Objective:To analyze the impact of the quality of homepage filling of medical records on the data grouping of DRGs.Method:61,730 medical records and DRGs data of the discharged patients in 2019 and 2021 were collected.Then,the quality of homepage filling of medical records was assessed for quality control;the error rate of filling in the core indicators of the homepage of medical records was calculated;and the correlation with DRGs data was analyzed.Result:There was a statistically significant difference in the error rate and the total error rate of the core indicators on the medical record homepage compared to two years ago(P<0.05).The error rate of major surgical and operational filling was negatively correlated with the Case Combination Index(CMI)(correlation coefficient r=-0.611,P=0.002);There is a negative correlation between the error rate of other diagnoses and coding entries and the total number of DRGs,and the number of DRGs groups(r=-0.649,-0.511,P=0.001,0.011);The total error rate of core indicators is negatively correlated with the total number of DRGs(r=-0.487,P=0.016).Conclusion:The incorrect filling of core indicators has a significant impact on the grouping of DRGs data.Therefore,strengthening the quality control of medical record homepage for its accuracy and completeness is an important prerequisite for improving the inclusion rate of DRGs.

关 键 词：病案首页 DRGS 相关性分析 

分 类 号：R197[医药卫生—卫生事业管理]