现代医院2024，Vol.24Issue(7)：1051-1054,4.DOI:10.3969/j.issn.1671-332X.2024.07.017
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
摘要
Abstract
Objective To analyze the implementation effect of quality control on the homepage of inpatient medical re-cords 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 in-cluded 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(χ2=144.11,P<0.05).The missing rates of diagnos-tic 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 medi-cal 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Key words
drg/inpatient Medical records/Homepage filling/Homepage quality control分类
医药卫生引用本文复制引用
何小萍,魏晓靓,何明聪,舒航,胡佳睿..基于DRG的住院病案首页质量控制实施效果研究[J].现代医院,2024,24(7):1051-1054,4.基金项目
东莞市社会发展科技项目(20211800905172) （20211800905172）
