基于病案首页前置质控平台的医保结算清单数据质量改进  

Data Quality Improvement of Medical Insurance Settlement List Based on Pre-Quality Control Platform of Medical Record Home Page

作　　者：李俊 马昭明[1] 袁培 李佳霖 黄彬 LI Jun;MA Zhaoming;YUAN Pei;LI Jialin;HUANG Bin(Network Information Center,Maternity and Child Health Care of Guangxi Zhuang Autonomous Region,Nanning 530001,Guangxi,China)

机构地区：[1]广西壮族自治区妇幼保健院网络信息中心,广西南宁530001

出　　处：《医学信息》2025年第9期64-67,共4页Journal of Medical Information

基　　金：广西壮族自治区卫生健康委自筹经费科研课题(编号:Z-A20230312)。

摘　　要：病案首页为医保结算清单的重要数据源,而医保结算清单作为DRG医保支付的唯一凭据,因此病案首页数据质量的好坏直接影响医保结算清单数据的准确性及DRG分组的结果。本文以提高病案病案首页数据质量为目标,阐述了首页质控平台的功能特点,说明了改进医保结算清单数据质量方法,详细说明了规则库的设置及基础字典对照的具体内容。同时采集了广西壮族自治区妇幼保健院上传的医保结算清单数据,汇总第一次上传无法通过接口校验的个案。通过对比分析发现使用首页质控平台及质控接口后医保结算清单上传成功率大大提升,节省了由于填写不规范而返修的时间成本和人力成本,规则设置简单,使用便捷,应用效果显著,最后提出了持续改善医保结算数据质量的难点和建议。The medical record home pageis an important data source for the medical insurance settlement list,and the medical insurance settlement list is the only basis for DRG medical insurance payment.Therefore,the quality of the data on the medical record home pagedirectly affects the accuracy of the medical insurance settlement list data and the results of DRG grouping.In order to improve the data quality of the medical record home page,this paper expounds the functional characteristics of the pre-quality control platform of the medical record home page,explains the method of improving the data quality of the medical insurance settlement list,and explains in detail the setting of the rule base and the specific content of the basic dictionary control.At the same time,the data of medical insurance settlement list uploaded by the Maternityand Child Health Care of Guangxi Zhuang Autonomous Region were collected,and the cases that could not pass the interface verification for the first time were summarized.Through comparative analysis,it is found that the success rate of uploading the medical insurance settlement list is greatly improved after using pre-quality control platform and quality control interface,which saves the time cost and labor cost of rework due to non-standard filling.The rule setting is simple,the use is convenient,and the application effect is remarkable.Finally,the difficulties and suggestions for continuously improving the quality of medical insurance settlement data are put forward.

关 键 词：病案首页前置质控平台 医保结算清单 数据质量 

分 类 号：R197[医药卫生—卫生事业管理]