摘要
目的利用DRGs医院分析检验X软件对医院病案首页质量进行审核,通过人工检查核实反馈错误,对比分析DRGs检测软件对病案首页质量筛查的效果。方法收集整理某医院经过三级质控的2020年第1季度电子病案首页数据,导入DRGs分组系统数据格式进行处理,X软件对其进行错误检测筛选。随机抽样200份,另由医院组建的审核组对抽样的200份错误病案逐条核实,对错误原因进行汇总、对比与分析。结果利用X软件筛选出的200份错误中,4例为未入组。在入组的196份首页错误病案中,非编码错误35例,编码错误161例;审核组对该200例错误病案首页进行核对,检出未入组7例,非编码错误30例,编码错误163例。X软件在对病案首页质量筛查中能起到积极作用,200份病案首页错误中大部分与实际情况相符合,但仍存在部分瑕疵。结论利用DRGs医院分析检验软件可以起到积极筛查作用,其效果仍需在实践中不断更新完善。
Objective To audit the quality of the first page of hospital medical records by using DRGs hospital analysis and inspection X software, verify the feedback errors by manual inspection, and compare and analyze the screening effect of DRGs testing software on the first page of medical records.Methods The first page data of electronic medical records in the first quarter of 2020, which had not passed quality control, were collected and sorted out, and imported into DRGs grouping system data format for processing. X software was used for error detection and screening, and 200 medical records were sampled randomly. In addition, the audit team set up by the hospital verified 200 sampled wrong medical records one by one, summarized, compared and analyzed the causes of errors.Results Among the 200 wrong medical records screened by X software, 4 were not included in the group. Among the 196 wrong medical records, there were 35 non-coding errors and 161 coding errors. The audit team checked the front pages of the 200 wrong medical records, and found that 7 cases were not included in the group, 30 cases were non-coding errors and 163 cases were coding errors. X software can play an active role in the quality screening of the front pages of medical records, and most of the errors on the front pages of 200 medical records are consistent with the actual situation, but there are still some defects.Conclusion DRGs hospital analysis and testing software can play an active role in screening, and its effect still needs to be constantly updated and improved in practice.
作者
刘吉羊
沈阳
Liu Jiyang;Shen Yang(Medical Record Statistics Department,Xiaogan Central Hospital,Xiaogan 432000,China;Medical Administration Department,Xiaogan Central Hospital,Xiaogan 432000,China)
出处
《中国医院统计》
2021年第5期477-480,共4页
Chinese Journal of Hospital Statistics
