DRG联合住院病案首页标准化控制对普外科病案缺陷的影响  

Influence of Standardized Control on the First Page of DRG Combined Inpatient Medical Records on the Defects of General Surgery Records

作　　者：王新芳[1] WANG Xin-fang(Lyuliang City People’s Hospital)

机构地区：[1]吕梁市人民医院

出　　处：《中国标准化》2024年第14期248-251,共4页China Standardization

基　　金：吕梁市软科学研究项目“医保按疾病诊断相关分组付费政策下病案首页质量控制模式研究”(项目编号:2021RKX-2-45)资助。

摘　　要：目的:探究DRG条件下联合住院病案首页标准化控制对普外科缺陷指标的影响。方法:选取吕梁市人民医院DRG联合住院病案首页标准化控制前后住院病案各1200份,对比分析DRG联合住院病案首页标准化控制前后普外科病例缺陷变化情况。结果:DRG分组下病案首页标准化控制后,普外科病案首页缺陷率为4.83%,DRG分组下病案首页标准化控制前缺陷率为20.25%,两组对比差异显著(P<0.05);对两组7项主要缺陷类型进行对比,标准化控制后各缺陷类型发生率均较标准化控制前更低,差异具有统计学意义(P<0.05);标准化控制后患者病案首页基本信息、住院过程和诊疗信息产生数据错误的概率明显降低(P<0.05)。结论:DRG与住院病案首页标准化控制相结合,可显著改善普外科病案首页填写质量以及病案管理水平,为病案首页质控提供依据,可推广应用。Objective:To explore the effect of standardized control of the first page of combined hospitalization medical records on the defect index of general surgery under DRG conditions.Methods:1200 inpatient records of DRG combined inpatient records were selected from Luliang City People’s Hospital before and after standardized control,and the defect changes of general surgery cases were compared and analyzed.Results:After standardized control of the front page of medical records in DRG group,the defect rate of the front page of medical records in general surgery group was 4.83%,and before standardized control of the first page of medical records in DRG group was 20.25%,the difference between the two groups was significant(P<0.05).The 7 main defect types of the two groups were compared,and the incidence of each defect type after standardized control was lower than that before standardized control,the difference was statistically significant(P<0.05).After standardized control,the probability of data errors in the basic information of the first page of patients’medical records,hospitalization process and diagnosis and treatment information was significantly reduced(P<0.05).Conclusion:The combination of DRG and the standardized control of the front page of hospital medical records can significantly improve the quality of filling in the first page of general surgery medical records and the level of medical records management,and provide a basis for the quality control of the first page of medical records,which can be popularized and applied.

关 键 词：DRG 住院病案首页 标准化控制 缺陷率 普外科 

分 类 号：R197.323[医药卫生—卫生事业管理]