Application of the Transfer and Discharge Sheet of Medical Record in"National Examination"and DRG Indicator Evaluation of Clinical Departments
Objective To explore the application of the data of the transfer and discharge sheet of medical record combined with the data of medical record home page in the performance appraisal of tertiary public hospitals and DRG main indicator evaluation in clinical departments.Methods The data of the transfer and discharge sheet of medical record and medical record home page of HIS in a tertiary general hospital in Guizhou Province from January to August 2022 were selected,and the diagnosis and treatment data of the transferred patients in different clinical departments during hospitalization were statistically segmented,combined with the data of the first page of medical records,the main indicators of"national examination"and DRG in each department were recalculated.Results 98.00%(49/50)of the clinical departments in the sample hospitals had transfer behavior.Compared with the data statistics of the medical record home page,the number of four-level and minimally invasive surgeries and the number of complications of surgical patients in different departments of the hospital were significantly change by the data statistics of the transfer and discharge sheet of medical record of the department.The increase was mainly in surgery,and the decrease was mainly in internal medicine.There were 37 departments with total weight changes,of which the most increased was the Department of Critical Care Medicine(increase of 39.41%),and the most reduced was the Department of interventional Medicine(decrease by 18.00%).There were 36 departments with changes in CMI.Conclusion Through the data of the transfer and discharge sheet of medical record,the performance evaluation indicators of patients with transfer behavior in different departments can be calculated more accurately and reasonably,which is conducive to objectively reflecting the workload,technical difficulty and medical quality of each department of the hospital.
transfer sheet of medical recordDRGperformance appraisal of tertiary public hospitals
NETL
NSTL
万方数据
