转科出科首页数据在科室“国考”和DRG指标评价中的应用  

Application of the Transfer and Discharge Sheet of Medical Record in“National Examination”and DRG Indicator Evaluation of Clinical Departments

作　　者：刘仕方 余昌胤 莫茗荞 陈玲丽 Liu Shifang;Yu Changyin;Mo Mingqiao(Affiliated hospital of Zunyi Medical University,Zunyi,Guizhou,563000,China;不详)

机构地区：[1]遵义医科大学附属医院,贵州遵义563000

出　　处：《中国医院管理》2024年第7期67-70,共4页Chinese Hospital Management

基　　金：贵州省卫生健康委科学技术基金项目(gzwkj2022-281)。

摘　　要：目的探索将转科出科首页数据结合出院病案首页数据应用于临床科室三级公立医院绩效考核和疾病诊断相关分组(DRG)主要指标评价。方法收集贵州省某三级甲等综合医院2022年1—8月HIS中转科出科首页和出院病案首页数据,对转科患者住院期间在不同临床科室的诊疗数据进行分段统计,结合出院病案首页数据,重新计算各科室“国考”和DRG主要指标。结果有98.00%(49/50)的临床科室发生转科行为;与出院病案首页数据相比,通过转科出科首页数据统计该院不同科室间四级手术和微创手术台(人)次数、手术患者并发症发生例数有明显变化,增加的主要为外科,减少的主要为内科;总权重变化的有37个科室,增加最多的是重症医学一科(增长39.41%),减少最多的是介入科(减少18.00%);病例组合指数(CMI)有变化的共36个科室。结论通过转科出科首页数据,可更加准确、合理地计算发生转科行为的病人在不同科室的“国考”和DRG主要指标,有利于客观反映医院各科室工作量、技术难度和医疗质量。Objective To explore the application of the data of the transfer and discharge sheet of medical record combined with the data of medical record home page in the performance appraisal of tertiary public hospitals and DRG main indicator evaluation in clinical departments.Methods The data of the transfer and discharge sheet of medical record and medical record home page of HIS in a tertiary general hospital in Guizhou Province from January to August 2022 were selected,and the diagnosis and treatment data of the transferred patients in different clinical departments during hospitalization were statistically segmented,combined with the data of the first page of medical records,the main indicators of“national examination”and DRG in each department were recalculated.Results98.00%(49/50)of the clinical departments in the sample hospitals had transfer behavior.Compared with the data statistics of the medical record home page,the number of four-level and minimally invasive surgeries and the number of complications of surgical patients in different departments of the hospital were significantly change by the data statistics of the transfer and discharge sheet of medical record of the department.The increase was mainly in surgery,and the decrease was mainly in internal medicine.There were 37 departments with total weight changes,of which the most increased was the Department of Critical Care Medicine(increase of 39.41%),and the most reduced was the Department of interventional Medicine(decrease by 18.00%).There were 36 departments with changes in CMI.Conclusion Through the data of the transfer and discharge sheet of medical record,the performance evaluation indicators of patients with transfer behavior in different departments can be calculated more accurately and reasonably,which is conducive to objectively reflecting the workload,technical difficulty and medical quality of each department of the hospital.

关 键 词：转科出科首页 疾病诊断相关分组 三级公立医院绩效考核 

分 类 号：R197.323.2[医药卫生—卫生事业管理]