摘要
目的C-DRGs应用背景下发现住院病案首页数据存在缺陷,对电子病历系统进行改进,提高病案首页质量。方法从C-DRGs系统提取某院2018年10月1日-2019年3月30日出院病案共48315份,针对首页缺陷进行数据分类和统计。结果48315份病案首页存在缺陷共4795份,其中数据空值885份,缺陷占比为18.3%,编码错误1832份,缺陷占比为37.9%,以及逻辑错误2078份,缺陷占比为43%。结论通过对电子病历系统病案首页设置非空值控制、增加系统提醒功能和智能化辅导模块等改进措施,保证首页填写完整性和准确性,从而提高C-DRGs入组率和准确性。
Objective Tofind and analyzed the defects of medical record homepages and improves the electronic medical record system under the background of C-DRGs application,so as to improve the quality of the front page of medical records.Methods From October 1 st,2018 to March 30 th,2019,a total of 48315 discharged medical records were extractedfrom C-DRGs system.And then,data classification and statistics were carried out for the defects on the front pages.Results There were 4795 defects on the front pages of 48315 medical records,of which 885 were null data,18.3%were defective,1832 were coding errors,37.9%were defective,and 2078 were logic errors,43%were defective.Conclusion By setting up non-null value control,adding system reminder function and intelligent counseling module on the front pages of the electronic medical record system,the completeness and accuracy of front pages filling could be guaranteed,so as to improve the rate and accuracy of C-DRGs grouping.
作者
谢友勉
袁方
许学军
符典娃
刘世平
曹萍
伍坤林
陈其君
许大国
XieYoumian;Yuan Fang;Xu Xuejun;Fu Dianwa;Liu Shiping;Cao Ping;Wu Kunlin;Chen Qijun;Xu Daguo(DepartmentofQualityManagement,Zhujiang Hospital of Southern Medical University,Guangzhou 510280,Guangdong Province,China)
出处
《中国病案》
2020年第1期40-42,112,共4页
Chinese Medical Record
基金
南方医科大学珠江医院院长基金(yzjj2018g103).
关键词
DRGS
病案首页
电子病历系统
Diagnose-Related Group
Medical record front pages
Electronic medical record system
