Abstract:

Objective　To explore the application value of standardized management of the home page information of inpatient medical records in accurate diagnosis related grouping (DRGs). Methods　One hundred and thirty-two medical cases managed by Department of Internal Medicine, Wuxi Second People's Hospital from January to December 2022 were retrospectively analyzed. The 66 cases under traditional management of conventional DRGs were set as a control group, including 34 males and 32 females; they were 22-49 (38.65±6.36) years old. The 66 cases under the standardized management of the homepage information of inpatient records were set as an experimental group, including 35 males and 31 females; they were 21-48 (38.23±6.25) years old. The accurate grouping of DRGs, and the satisfaction of medical staff, and DRGs grouping error rates were compared between the two groups. χ² and t tests were applied. Results　The experimental group had a higher DRGs grouping standard rate and a lower rate of medical record repair than the control group [81.82% (54/66) vs. 60.61% (40/66) and 6.06% (4/66) vs. 19.70% (13/66)], with statistical differences (χ²=7.246 and 5.469; both P<0.05). The satisfaction score of the experimental group was higher than that of the control group [(25.36±1.38) vs. (20.21±1.14)], with a statistical difference (t=5.854, P<0.05). The total incidence of errors in the experimental group was significantly lower than that in the control group [4.55% (3/66) vs. 18.18% (12/66)], with a statistical difference (χ²=6.092, P<0.05). Conclusions　The application of standardized management of the home page information of inpatient medical records in the accurate grouping of DRGs can improve the quality of medical records and the satisfaction of medical staff, and reduce the total incidence of errors. It is worth being generalized in medical institutions.

Key words:

Standardized management, Medical record home page information, Disease diagnosis related grouping, Satisfaction, Error rate

摘要：

目的　探讨规范化管理住院病案首页信息在疾病诊断相关分组（DRGs）准确分组中的应用价值。方法　回顾性分析2022年1月至12月无锡市第二人民医院内科接受管理的132例病案，将采取传统常规DRGs管理的66例病案划分为对照组，其中男34例，女32例，年龄22～49（38.65±6.36）岁；采取规范化管理住院病案首页信息的66例病案划分为试验组，其中男35例，女31例，年龄21～48（38.23±6.25）岁。对比两组DRGs准确分组情况、医护人员满意度和DRGs分组差错率。统计学方法采用χ²检验、t检验。结果　试验组DRGs分组规范率高于对照组，病案返修率低于对照组［81.82%（54/66）比60.61%（40/66）、6.06%（4/66）比19.70%（13/66）］，差异均有统计学意义（χ²=7.246、5.469，均P<0.05）。试验组医护人员满意度评分高于对照组［（25.36±1.38）分比（20.21±1.14）分］，差异有统计学意义（t=5.854，P<0.05）。试验组差错的总发生率低于对照组［4.55%（3/66）比18.18%（12/66）］，差异有统计学意义（χ²=6.092，P<0.05）。结论　规范化管理住院病案首页信息应用于DRGs准确分组中，可提高病案质量与医护人员满意度，减少差错的总发生率，值得医疗机构推广应用。

关键词:

规范化管理, 病案首页信息, 疾病诊断相关分组, 满意度, 差错发生率