基于DRG的住院病案首页质量控制实施效果研究  

Research on the implementation effect of quality control of inpatient medical record homepage based on DRG

作　　者：何小萍[1] 魏晓靓 何明聪 舒航 胡佳睿 HE Xiaoping;WEI Xiaoliang;HE Mingcong;SHU Hang;HU Jiarui(Dongguan People’s Hospital,Dongguan 523000,China)

机构地区：[1]东莞市人民医院,广东东莞523000

出　　处：《现代医院》2024年第7期1051-1054,共4页Modern Hospitals

基　　金：东莞市社会发展科技项目(20211800905172)。

摘　　要：目的分析基于疾病诊断相关分组(disease diagnosis-related groups;DRG)的住院病案首页质量控制实施效果。方法研究回顾性纳入东莞市人民医院2018年-2022年共病案20000份,DRG住院病案首页质量实施控制前(2018年1月-12月)病案10000例为研究对照组;纳入DRG住院病案首页质量实施控制后(2022年1月-2022年12月)病案10000例为观察组,探究基于DRG背景下组间住院病案首页质量控制实施效果。结果对照组存在缺陷问题病案共1943份,占比19.43%,影响DRG入组共1000份(51.47%),不影响DRG入组共943份(48.53%);观察组存在缺陷问题病案共1316份,占比(13.16%),其中影响DRG入组共有643份,占比48.86%,不影响DRG入组的共有673份,占总质控错误的51.14%,组间缺陷病案份数差异统计学意义成立(χ^(2)=144.11,P<0.05);观察组患者诊疗信息、费用信息缺项率均低于对照组(P<0.05);观察组诊断及手术情况等填写完整正确率均高于对照组(P<0.05)。结论基于DRG背景的住院病案首页质量控制实施能显著提升住院病案首页质量,提升住院病案首页诊断及手术情况等填写正确率,综合性质控价值更高,建议临床推广使用。Objective To analyze the implementation effect of quality control on the homepage of inpatient medical records based on the background of Disease Diagnosis Related Groups(DRG).Methods A retrospective study was conducted,including a total of 20,000 medical records from Dongguan People’s Hospital from 2018 to 2022.Among them,10,000 medical records from January to December 2018,before the implementation of DRG-based quality control,were included as the control group;10,000 medical records from January to December 2022,after the implementation of DRG-based quality control,were included as the observation group.The implementation effect of quality control of hospital admission medical records among different groups based on DRG was explored.Results In the control group,there were 1,943 medical records with defects,accounting for 19.43%,which affected DRG grouping in 1,000 cases(51.47%)and did not affect DRG grouping in 943 cases(48.53%).In the observation group,there were 1,316 medical records with defects,accounting for 13.16%,among which 643 cases(48.86%)affected DRG grouping and 673 cases(51.14%)did not affect DRG grouping.The difference in the number of defective medical records between the groups was statistically significant(χ^(2)=144.11,P<0.05).The missing rates of diagnostic and treatment information and cost information in the observation group were lower than those in the control group(P<0.05).The completeness and accuracy rates of diagnosis and surgical information in the observation group were higher than those in the control group(P<0.05).Conclusion The implementation of quality control of hospital admission medical records based on DRG can significantly improve the quality of medical records,increase the accuracy of diagnosis and surgical information in medical records,and have higher comprehensive quality control value.It is recommended for clinical promotion and use.

关 键 词：DRG 住院病案 首页填写 首页质量控制 

分 类 号：R197.3[医药卫生—卫生事业管理]