摘要
Abstract
Objective To observe the impact of quality control of inpatient medical record front pages based on Diagnosis-Related Groups(DRGs)on the completeness and accuracy of front page entries and provide a reference for clinical practice.Methods A total of 384 inpatient medical records from December 1,2022,to February 28,2023,before DRGs quality control,were selected as the control group,while 406 inpatient medical records from March 1,2023,to May 31,2023,after DRGs quality control,were selected as the observation group.The control group patients received conventional medical record management,while the observation group patients were subjected to quality control under the DRGs framework.The qualification rate and omission rate of front page quality between the two groups were compared,as well as the accuracy rates of primary and other diagnoses,surgical procedures,and diagnostic codes.Results The front page quality qualification rate in the observation group was higher than that of the control group,and the omission rate was lower,with statistically significant differences(P＜0.05).The accuracy rates of the primary diagnosis,primary surgical procedure,and primary diagnostic codes in the observation group were higher than those in the control group,with statistically significant differences(P＜0.05).Furthermore,the accuracy rates of other diagnoses,other surgical procedures,and other diagnostic codes in the observation group were higher than those in the control group,with statistically significant differences(P＜0.05).Conclusion Management of inpatient medical record front pages based on DRGs improves the completeness and accuracy of these records,ensuring data correctness.Clinical practice should emphasize the quality of medical record front pages.关键词
疾病诊断相关分组/病案首页/质量控制/完整性/准确性Key words
Diagnosis-Related Groups/Medical Record Front Page/Quality Control/Completeness/Accuracy分类
药学
