DRG背景下病案科的精细化管理  

Refined Management of the Medical Records Department Under the Background of DRG

作　　者：黎俊 周王艳 唐再丽 Li Jun;Zhou Wangyan;Tang Zaili(The Second Affiliated Hospital,Department of DRG,Hengyang Medical School,University of South China,Hengyang 421000,Hunan Province,China;不详)

机构地区：[1]南华大学衡阳医学院南华大学附属第二医院DRGs办公室,湖南省衡阳市421000 [2]南华大学衡阳医学院南华大学附属第一医院病案室,湖南省衡阳市421001

出　　处：《中国病案》2024年第5期6-8,共3页Chinese Medical Record

基　　金：2021年度湖南省社会科学成果评审委员会课题立项(XSP21YBC384)。

摘　　要：DRG工作在我国全面铺开,为了适应DRG医保支付带来的挑战,病案科需要提升全面精细化管理。以某院病案科为例,优化病案签收归档流程、实现历史病案的数字化以及未来病案的无纸化;优化病案首页质控流程,采用出院病案的1次全流程4级质控审核体系和医保DRG分组返回问题病案的2次全流程审核,实现智能辅助编码,新增病案反馈功能、编码质控和结果显示功能,实时反馈给编码员,实施病案统计信息化,通过培训统计人员数据库知识,实现数据库统计查询;加强人员储备和人才培训。通过以上途径实现工作效率和工作质量的提高,实现病案首页书写和编码质量的提高,使医院在DRG医保支付中实现收支平衡。DRG(Diagnosis Related Groups)work is rapidly and comprehensively spreading in China.In order to adapt to the challenges brought by DRG medical insurance payment,the medical records department must adopt comprehensive and refined management.Taking a certain hospital as an example,refined management will be achieved from the following three aspects.First,the medical record signing and archiving process is optimized,the digitization of historical medical records is realized,and future medical records are made paperless.Second,the quality control process on the front page of medical records is optimized.A full-process 4-level quality control review system for discharged medical records and two full-process reviews of problematic medical records returned by medical insurance DRG groups are adopted.Intelligent auxiliary coding is realized,while the medical record feedback function,coding quality control,and result display function are added.Real-time feedback to coders is provided,and medical record statistics informatization is implemented.Database statistical queries by training statisticians on database knowledge are implemented.Third,personnel reserves and talent training are strengthened.Through the above methods,work efficiency and work quality can be improved,and the quality of writing and coding on the front page of medical records can be improved so that the hospital can achieve a balance between revenue and expenditure in DRG medical insurance payment.

关 键 词：病案科 DRG 精细化管理 

分 类 号：R197.323[医药卫生—卫生事业管理]