Analysis of Defects on the Front Page of Inpatient Medical Records in 158 Medical Institutions Based on Disease Score Payment
Objectives This study aims to analyze the quality of the home pages of inpatient medical records in 158 hospitals in Suqian City and propose countermeasures based on the influencing factors of payment based on disease type scores,so as to provide scientific and effective reference to further improve the quality of inpatient medical record front page in Suqian City.Methods According to the principle of all tertiary hospitals,95％secondary hospitals and 60％primary hospitals,and the discharge volume of primary,secondary,and tertiary hospitals is greater than 100,400,and 4500 person-time respectively,582,292 front pages of hospitalized medical records of discharged patients from 158 hospitals in the electronic medical record quality control platform of Suqian City from January 1 to December 31,2021 were randomly selected.Automatic quality control was carried out according to the standard requirements of filling in the front page of inpatient medical records on the platform.Quality control results were classified into two parts according to mandatory and conditional items.SPSS23.0 was used to analyze the data and calculate the completion rate,upload rate,average score,excellent rate,proportion of defects in required items,proportion of defects in conditionally required items,and workload of coders on the front page of inpatient medical records.A t-test was performed on the average score of the front page of inpatient medical records.Results The completion rate and upload rate of tertiary hospitals were both 100％,and the rates of first and second-tier hospitals were over 90％.The average score of tertiary hospitals was 97.93 points,that of second-level hospitals was 90.99 points,and that of first-level hospitals was 87.17 points.The independent sample t-test was statistically significant.There were 453,950 defective front pages of hospitalization medical records,accounting for 77.96％.Among them,there were 1,371,524 required deficiencies,accounting for 22.03％.There were 4,854,625 defects in the required items,accounting for 77.97％of the defects.Among them,the main defect of the tertiary hospitals was that the autopsy was filled in incorrectly,accounting for 30.9％;the main defect of the second-level hospitals was that other diagnoses or codes were not filled in,accounting for 68.6％;the main defect of the first-level hospitals was that the discharge diagnosis was not filled in or filled in incorrectly,accounting for 99.7％.Coders in tertiary hospitals had the greatest workload.Conclusions There are deficiencies in filling out the front page of inpatient medical records in hospitals at all levels,and the quality of the first page of inpatient medical records in tertiary hospitals is relatively good.The defects of required items on the front page of inpatient medical records at all levels accounted for the highest proportion.There are mainly logical misunderstanding errors in the third-level hospitals,and there are mainly diagnostic coding errors in the first-and second-level hospitals.At the same time,the allocation of coders in hospitals at all levels is unreasonable.It shows that hospitals at all levels need to further strengthen the quality of filling in the home pages of inpatient medical records and promote continuous improvement on the home pages of inpatient medical records.
DIP paymentFront page of inpatient medical recordsDefect analysisContinuous improvement
NETL
NSTL
万方数据
维普
