Analysis on the Data Quality of Front Page of Medical Record in a Three A and Tertiary Stomatology Hospital in Hubei Province
Objectives This paper analyzed the data quality of the front page of inpatient medical records that included DRG payment in a Three A and Tertiary Stomatology Hospital in Hubei Province,and provided reference for improving the data quality of the front page of inpatient medical records in stomatology hospitals and promoting DRG payment.Methods 1604 front pages of medical record uploaded by a Three A and Tertiary Stomatology Hospital in Hubei Province from 2020 to 2021 were selected.Descriptive analysis and rank sum test were used to analyze enrollment,weight distribution,causes of unqualified quality control and ambiguous cases.Results There were 1524 front pages of medical record passed the quality control and enrolled into DRG groups.The distribution of weight of DRG groups was significantly different(Z =-3.74,P＜0.01),the rate of higher weight above 1.2 in 2021 was higher than that in 2020.There were 80 unqualified front pages of medical record,here were 143 unqualified items in total,the highest proportion of unqualified items of quality control rationality was 71.33%,and the unqualified items related to diagnosis and disease coding accounted for 72.02%.40 cases entered the ambiguous group,accounting for 2.49%,and the imperfect subgroup scheme accounted for the highest 80.00%.Conclusions The data quality control qualification rate and enrollment rate of the front page of inpatient medical records in this hospital were relatively high.The reasons for data errors of unqualified quality control cases and QY cases included errors in coding conversion and data extraction of the information system of medical institutions,non-standard writing by clinicians,and unfamiliarity of coders with the rules of using the medical insurance code database.
Diagnosis Related GroupStomatology hospitalFront page of medical recordQuality control
NETL
NSTL
万方数据
