医疗保险机构实施单病种付费结算方式,病案成为单病种准入和医疗保险机构支付医院费用的重要依据,也关系到对实施单病种结算科室的考核评价。通过对单病种结算病案的审核,发现病案中存在诊断缺陷、病程记录中对病情分析、治疗等记录的不完整性,不能充分反映医疗诊治的过程。因此,医院需要不断加强病案书写质量的提高,这不仅是医疗质量和医疗安全的体现,也是医保部门监督审核医疗费用的客观依据。 Medical insurance institutions to implement a single disease payment settlement, medical records into a single disease access and medical insurance agencies to pay an important basis for hospital costs, but also related to the implementation of single disease settlement department evaluation. Through examining the medical record of the single disease settlement, it is found that there is a diagnosis defect in the medical record, and the incomplete record of the analysis and treatment of the disease record in the course record can not fully reflect the medical diagnosis and treatment process. Therefore, the hospital needs to continuously improve the quality of medical record writing, which is not only an indication of the medical quality and medical safety, but also an objective basis for the medical insurance department to supervise and audit medical expenses.