基于DRG付费分析湖北省某三甲口腔医院住院病案首页数据质量  

Analysis on the Data Quality of Front Page of Medical Record in a Three A and Tertiary Stomatology Hospital in Hubei Province

作　　者：沈小勇 李智勇 段磊[2] Shen Xiaoyong;Li Zhiyong;Duan Lei(Hospital of Stomatology,Wuhan University,Wuhan 430079,Hubei Province,China;不详)

机构地区：[1]武汉大学口腔医院,湖北省武汉市430079 [2]华中科技大学医药卫生管理学院,湖北省武汉市430030

出　　处：《中国病案》2024年第4期16-20,共5页Chinese Medical Record

基　　金：中国牙病防治基金会资助项目(FX202319)。

摘　　要：目的分析湖北省某三甲口腔医院纳入DRG付费的住院病案首页数据质量情况,为提高口腔专科医院住院病案首页数据质量和促进DRG付费工作提供参考。方法全样本选取湖北省某三甲口腔专科医院2020年1月1日-2021年12月31日纳入DRG付费的1604份住院病案首页数据,采用描述性分析和秩和检验分析入组情况、权重分布、质控不合格原因及歧义病例。结果该院1604份纳入DRG付费结算患者的住院病案首页,1524份质控合格(合格率95.01%)并进入DRG分组。入组病例DRG权重分布差异有统计学意义(Z=-3.74,P=0.000),2021年高权重组(1.2以上)病例占比80.02%,高于2020年(73.36%)。80份住院病案首页质控不合格(4.99%)未进行DRG分组,共计143个不合格项,质控合理性不合格项占比最高为71.33%,与诊断和疾病编码相关的不合格项目共计占比72.02%。40例病例进入歧义组,占比2.49%,细分组方案不完善占比最高为80.00%。结论该院住院病案首页数据质控合格率、入组率较高,质控不合格病例和QY病例的数据错误原因包括医疗机构信息系统进行编码转换及提取数据有误、临床医师书写不规范、编码员不熟悉医保编码库使用规则等。Objectives This paper analyzed the data quality of the front page of inpatient medical records that included DRG payment in a Three A and Tertiary Stomatology Hospital in Hubei Province,and provided reference for improving the data quality of the front page of inpatient medical records in stomatology hospitals and promoting DRG payment.Methods 1604 front pages of medical record uploaded by a Three A and Tertiary Stomatology Hospital in Hubei Province from 2020 to 2021 were selected.Descriptive analysis and rank sum test were used to analyze enrollment,weight distribution,causes of unqualified quality control and ambiguous cases.Results There were 1524 front pages of medical record passed the quality control and enrolled into DRG groups.The distribution of weight of DRG groups was significantly different(Z=-3.74,P<0.01),the rate of higher weight above 1.2 in 2021 was higher than that in 2020.There were 80 unqualified front pages of medical record,here were 143 unqualified items in total,the highest proportion of unqualified items of quality control rationality was 71.33%,and the unqualified items related to diagnosis and disease coding accounted for 72.02%.40 cases entered the ambiguous group,accounting for 2.49%,and the imperfect subgroup scheme accounted for the highest 80.00%.Conclusions The data quality control qualification rate and enrollment rate of the front page of inpatient medical records in this hospital were relatively high.The reasons for data errors of unqualified quality control cases and QY cases included errors in coding conversion and data extraction of the information system of medical institutions,non-standard writing by clinicians,and unfamiliarity of coders with the rules of using the medical insurance code database.

关 键 词：疾病诊断分组 口腔医院 住院病案首页 质量控制 

分 类 号：R197.5[医药卫生—卫生事业管理]