按疾病诊断相关分组付费改革下病历信息利用与管理  

Utilization and management of medical record information under DRGs payment reform

作　　者：刘雪华 冯韬 梁倩 LIU Xuehua;FENG Tao;LIANG Qian(Wuming Hospital of Guangxi Medical University,Nanning,Guangxi,530199,China)

机构地区：[1]广西医科大学附属武鸣医院,广西南宁530199

出　　处：《当代医学》2023年第35期187-190,共4页Contemporary Medicine

基　　金：广西中医药管理局2020年自筹经费科研课题(GZZC2020211)。

摘　　要：病历管理的主要目的是为社会及医院提供服务,而病历管理工作的归宿与出发点是病历信息的利用。因此,科学、合理的保存病历资料,最大程度的提高病历书写质量,不仅能直接反映医院的医疗质量水平,还能体现医院的整体管理水平。近年来,随着医疗保险事业的快速发展,各个国家开始实施了按疾病诊断相关分组(DRGs)付费模式,其不仅解决了目前社会群体所反映的“看病贵”“看病难”等各种医疗行业相关问题,还为社会提供更加良好的医疗服务。但在DRGs付费模式推行的背景下,医院也越来越重视病历信息化的建设工作。基于此,通过主要对DRGs付费改革下病历信息利用与管理进行综述,为各大医疗机构提供参考,提升医院病历信息的利用率与管理能力。The main purpose of medical record management is to provide services for society and hospitals,and the destination and starting point of medical record management is the utilization of medical record information.Therefore,scientific and reasonable preservation of medical record data and maximum improvement of medical record writing quality can not only directly reflect the medical quality level of the hospital,but also reflect the overall management level of the hospital.In recent years,with the rapid development of medical insurance,various countries began to implement the diagnosis related groups(DRGs)payment model.It not only solves various medical industry related problems such as"expensive to see a doctor"and"difficult to see a doctor"reflected by today's social groups,but also provides better medical services for the society.However,under the background of the implementation of DRGs payment mode,hospitals also pay more and more attention to the construction of medical record informatization.Based on this,this paper mainly summarizes the utilization and management of medical record information under the DRGs payment reform,so as to provide reference for major medical institutions and improve the utilization and management ability of hospital medical record information.

关 键 词：按疾病诊断相关分组付费 改革 病历信息 管理 

分 类 号：R197.32[医药卫生—卫生事业管理]