DRGs付费模式下中医病案首页质控研究  

Research on Quality Control of the Front Page of TCM Medical Records Under DRGs Payment Mode

作　　者：王明飞 肖晓兰[2] 粟保元 WANG Ming-fei;XIAO Xiao-lan;SU Bao-yuan(Department of Quality Control,Guilin Hospitals of Chinese Traditional and Western Medicine,Guilin 541004,Guangxi,China;Medical Record Room of Guangxi Zhuang Autonomous Region Tumor Hospital Information Center,Nanning 530021,Guangxi,China)

机构地区：[1]桂林市中西医结合医院质控科,广西桂林541004 [2]广西壮族自治区肿瘤医院信息中心病案室,广西南宁530021

出　　处：《医学信息》2024年第15期173-176,共4页Journal of Medical Information

基　　金：广西中医药管理局自筹经费科研课题(编号:GXZYC20220511)。

摘　　要：病案首页信息囊括了患者住院期间整个诊疗过程,是实施DRGs付费的关键部分。新医改以来,医保DRGs支付已广泛应用于我国大部分的大型综合性医院和各种医疗机构,并逐渐在全国进行推广,在此背景下,如何提高住院病案首页内涵质量是当前医院管理部门所面临的首要问题。因此,本文就病案首页常见缺陷问题、对DRGs分组造成的影响、病案首页控制方法研究进展作一综述,期待医疗机构结合医院实际情况,制定一套行之有效的质控方式,保证中医住院病案首页的完整性和准确性,达到在减轻临床医生负担的同时提高中医病案首页质量,为医疗改革和医院管理奠定坚实的数据基础。The information on the front page of the medical record covers the whole process of diagnosis and treatment during the hospitalization of patients,which is a key part of the implementation of DRGs payment.Since the new medical reform,medical insurance DRGs payment has been widely used in most large general hospitals and various medical institutions in China,and has been gradually promoted throughout the country.Under this background,how to improve the connotation quality of the front page of inpatient medical records is the primary problem faced by the current hospital management department.Therefore,this paper reviews the common defects of the first page of medical records,the impact on DRGs grouping,and the research progress of the control methods of the first page of medical records.It is expected that medical institutions will formulate a set of effective quality control methods in combination with the actual situation of the hospital to ensure the integrity and accuracy of the first page of medical records of traditional Chinese medicine,so as to reduce the burden of clinicians and improve the quality of the first page of medical records of traditional Chinese medicine,and lay a solid data foundation for medical reform and hospital management.

关 键 词：DRGs付费 中医病案首页 质控研究 

分 类 号：R197.323[医药卫生—卫生事业管理]