[1]张中花,章浩然.基于DRG的安徽某大型三甲医院病案首页质量改进研究[J].卫生经济研究,2020,(03):29-31,35.
　ZHANG Zhong-hua,ZHANG Hao-ran.Research on the Improvement of the Quality of the First Page of Medical Records in a Large III-A Hospital in Anhui Based on DRG[J].Journal Press of Health Economics Research,2020,(03):29-31,35.
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基于DRG的安徽某大型三甲医院病案首页质量改进研究
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卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:
期数:
2020年03期
页码:
29-31,35
栏目:
医保天地
出版日期:
2020-03-04

文章信息/Info

Title:
Research on the Improvement of the Quality of the First Page of Medical Records in a Large III-A Hospital in Anhui Based on DRG
作者:
张中花1; 章浩然1
1.皖南医学院第一附属医院弋矶山医院，安徽 芜湖 241000
Author(s):
ZHANG Zhong-hua; ZHANG Hao-ran
The First Affiliated Hospital of Wannan Medical College，Wuhu Anhui 241000，China
关键词:
DRG入组因素; 病案管理; 首页质量
Keywords:
DRG entry factors; medical record management; quality of first page of medical records
分类号:
R197.322
文献标志码:
A
摘要:
目的：基于DRG入组因素，找出医院病案首页项目填写存在的问题，制定有效的病案管理措施，为推行DRG付费提供保证。方法：检索某院2019年1—6月出院的病案首页52 596份，基于DRG统计缺陷项目，计算缺陷率，找出重要缺陷项目。结果：根据DRG入组因素，发现病案首页项目漏填率较低（2.38%）；错填率整体较高，排名前三的项目是付费方式（25.12%）、ICD-10及ICD9-CM-3编码（21.58%）、手术切口愈合等级等（9.41%）。结论：通过加大DRG宣传力度、加强信息化建设及相关人员培训、规范诊断
Abstract:
Objective To find out the existing problems in filling out the first page of the hospital medical record，formulate effective medical record management measures，and provide guarantee for the implementation of DRG payment based on the DRG enrollment factors. Methods 52 596 first pages of medical records discharged in a hospital from January to June 2019 were retrieved. Based on the DRG statistical defect items，the defect rate was calculated to find important defect items. Results According to the DRG enrollment factors，it was found that the missed fill rate of the first page of the medical record was low (2.38%)；the wrong fill rate was generally high，and the top three items were the payment method (25.12%)，ICD-10 and ICD9-CM-3 codes (21.58%)，surgical incision healing grade，etc. (9.41%). Conclusion The quality of the first page of the medical records should be continuously improved by increasing the efforts of DRG publicity，strengthening the construction of informatization and related personnel training，and standardizing the standards of the diagnostic database.

参考文献/References:

[1] 张丽敏,杨建玲,王丽君，等.基于DRGs的病案首页质量分析[J].中国卫生质量管理，2019(1)：33-35.
[2] 张中花.病案首页书写缺陷分析及解决对策[J].医学信息,2019,32(6):29-31.
[3] 姚建灵,邹伟明,李莹. 采用DRGs分组方式提高病案首页填写质量探究[J].管理观察，2018(34)：185-186.
[4] 曾姝,严少彪,李准,等. DRGs形势下病案首页质量控制体系的建立与应用[J].现代医院管理,2017(6):21-24.
[5] 王怡,马云波,樊美娜，等. 试行DRGs后住院病案首页督导检查方法[J].中国病案，2017(9)：12-15.
[6] 苏静,陈冬连,朱艳艳，等. 基于DRGs数据的4 382例恶性肿瘤病案主要诊断选择的分析[J]，中国病案，2017(9)：15-18.
[7] 徐小平,于千惠,邓东宁,等. DRGs在医院管理中应用的研究现状[J].卫生经济研究,2018(5):66-68.
[8] 季新强,张耀光. DRGs方法在临床亚专科医疗服务绩效评价中的应用[J].中国医院管理,2017(1):34-37.
[9] 李乐乐,俞乔.云南省玉溪市DRGs付费改革的实践探索[J].卫生经济研究,2019,36(3):47-48,52.
[10] 王怡. DRGs形势下住院病案首页信息面临的挑战和对策[J].中华医院管理杂志，2015 (11)：831-833.

更新日期/Last Update: 2020-03-04