A Comparative Analysis on the Quality of Filling in the Front Page of Inpatient Medical Records in the Neurology Department of a Tertiary Hospital in Beijing
Objectives The quality of filling in the fron page of inpatient medical records in the neurology department of a hospital under the background of DRG was compared and analyzed,thus to provide reference for improving data quality.Methods A total of 3060 inpatient medical records from January 1st,2023 to June 30th,2023 were selected as the control group,and 3000 inpatient medical records from July 1st,2023 to December 31st,2023 were selected as the observation group.The control group used traditional medical record room coders and clinical department quality control teams for quality control;On the basis of the control group,the observation group collaborates with the Medical Record Management Committee for quality control,and the quality control results are fed back layer by layer to the leaders of the responsible hospital and the Medical Record Management Department.The upper and lower levels collaborate to supervise clinical physicians in the neurology department to improve the quality of medical record writing on the front page.Both groups used the DRG system to evaluate and analyze the overall situation of hospitals in neurology in the first and second half of 2023,and to explore the effectiveness of quality control on inpatient medical records under the background of DRG.Results The missing items on the front page of inpatient medical records in the neurology department decreased in 2023(P<0.05),with the error rate of coding for major diagnostic choices decreasing from 4.74%to 3.30%,the error rate of coding for other diagnostic choices decreasing from 6.47%to 3.37%,the error rate of coding for major surgical procedures decreasing from 3.20%to 1.60%,and the error rate of missing other mandatory items decreasing from 9.02%to 5.90%.The differences between the two groups were statistically significant.In terms of DRG indicators,the number of DRG groups increased from 89 to 101,the CMI value increased from 1.29 to 1.48,the proportion of low weights decreased from 38.18%to 30.14%,the time consumption index decreased from 1.09 to 1.02,the cost index decreased from 0.98 to 0.81,and the low-risk mortality rates were all 0.Conclusions The multi-linkage quality control mode based on DRG payment could improve the data filling quality of the front page of inpatient medical records,reduce the error rate and missing filling rate of diagnosis and surgical operation,and thus improve the quality of the front page of inpatient medical records.
DRGNeurology departmentInpatient medical record front pageQuality control system