DRG支付背景下病案首页质量预审核管理的研究  

Research on the quality pre-audit management of the first page of medical records under the background of DRG payment

作　　者：陈小涵 董晨雪 章梦恬 廉欣月 张明华[1] CHEN Xiaohan;DONG Chenxue;ZHANG Mengtian;LIAN Xinyue;ZHANG Minghua(The Second Affiliated Hospital of Soochow University,Suzhou 215004,China;School of Politics and Public Administration,Soochow University,Suzhou 215123,China)

机构地区：[1]苏州大学附属第二医院,江苏苏州215004 [2]苏州大学政治与公共管理学院,江苏苏州215123

出　　处：《现代医院》2024年第6期874-877,984,共5页Modern Hospitals

摘　　要：目的通过探讨预审核管理在病案首页质量管理中的作用,研究提升病案首页质量、助力DRG支付的可行之策。方法分析苏州市某三甲医院在提高病案首页质量中的新举措,并分析其2023年出院的2644份病历质量。结果为了顺利开展DRG支付工作,苏州市某三甲医院创新性地建立了病案首页质量预审核管理机制,在一定程度上提升了病案首页质量,但仍存在病案首页填写不规范、病历数据不一致和病历文书完成不及时的问题。结论医院在贯彻落实病案首页质量预审核管理的同时,应采用凝聚共识,重视病案首页质量管理工作;规范填写,确保病案首页数据精确完整;沟通协作,提升医院DRG工作软硬实力;完善考核,优化病案首页管理激励机制的方式,提高病案首页质量,助力DRG支付。Objective This paper discusses the role of pre-audit management in the quality management of the first page of medical records,and studies the feasible measures to improve the quality of the first page of medical records and assist DRG payment.Methods This paper analyzes the new measures to improve the quality of the first page of medical records in an A-Class tertiary hospital in Suzhou,and analyzes the quality of 2644 medical records discharged during 2023.Results In order to effectively respond to the DRG payment reform,an A-Class tertiary hospital in Suzhou innovatively established a pre-audit management mechanism,and improved the quality of the first page of medical records to a certain extent,but there are still problems such as non-standard filling,inconsistent medical record data and untimely completion of medical record documents.Conclusion The hospital should build consensus,attach importance to the quality management;standardize the filling,ensure the accuracy and completeness;communicate and collaborate,improve the soft and hard power of the hospital;improve the assessment,and optimize the incentive mechanism for the management to improve the quality of the first page of medical records and assist DRG payment.

关 键 词：病案首页 质量控制 DRG 预审核管理 

分 类 号：R197.323.1[医药卫生—卫生事业管理]