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目的北京医疗保险2013年实现总额预付,DRGs分组是住院病人付费管理的重要评价工具,为了提高DRGs分组数据的上传质量,有必要规范病案首页诊断书写。方法通过加强DRGs知识宣传培训;借助信息化的手段,建立标准化的疾病诊断名称同义词数据库;利用信息化手段建立可视的诊断书写平台等方法提高诊断正确率。通过利用我院两年DRGs数据与北京市的分析对比,让医院管理人员和临床医生了解诊断填写的问题所在以及分组相关数据与北京市平均水平的差距。结果临床医生填写好诊断和病案首页的水平显著提升,2012年我院DRGs数据质量显著提高。结论达到临床医生积极参与的管理目标,提升我院DRGs数据质量。
Objective Beijing Medical Insurance realized total prepayment in 2013. DRGs grouping is an important evaluation tool for inpatient payment management. In order to improve the quality of DRGs grouping data upload, it is necessary to standardize the first page of medical record diagnosis. Methods To promote the training of DRGs knowledge by means of informationization, to establish a standardized synonym database for disease diagnosis, and to establish a visual diagnostic writing platform by means of information technology to improve the diagnosis accuracy. Through the use of DRGs data in our hospital for two years and Beijing’s analysis of contrast, so that hospital managers and clinicians to understand the diagnosis and fill in the problem where the data and the packet-related gap with Beijing’s average. Results The clinician filled in the first page of diagnosis and medical records significantly, and the data quality of DRGs in our hospital increased significantly in 2012. Conclusions The goal of clinicians’ active participation is achieved and the data quality of DRGs in our hospital is improved.