Quality Analysis of Front Pages of Inpatient Medical Records in Rehabilitation Medical Department of a Hospital Before and After DRGs Implementation
Objective To explore the quality of front pages of inpatient medical records in the implementation of disease diagnosis related grouping(DRGs)in the rehabilitation medical department of a hospital.Methods Based on the electronic medical records information database of our hospital,the quality control system was established by setting up a special quality control expert group,developing a quality control score table on the front page of inpatient medical records,and electronic verification,and the inpatient medical records of rehabilitation medical treatment before the implementation of DRGs in our hospital at the end of 2018 to 2020 were set as the control group(n=600).The inpatient medical records of rehabilitation medical treatment after the implementation of DRGs in our hospital from 2021 to 2023 were set as the experimental group(n=600),and the timeliness,accuracy and completeness of various information in the two groups were statistically analyzed.Results The missing information of basic information,hospitalization process information,diagnosis and treatment information and cost information of patients in the experimental group were 3.67%,4.17%and 29.00%,respectively,and those in the control group were 22.17%,13.17%and 45.17%,which were significantly lower in the two groups than in the experimental group(P<0.05).There was no significant difference in the timeliness of archiving of medical records between the two groups(P>0.05).The correct rate of main diagnosis selection,other diagnosis,enrollment accuracy and coding accuracy of the experimental group were significantly higher than those of the control group(all P<0.05).The test accuracy of experimental group was significantly higher than that of control group(P<0.05).The integrity of the experimental group was better than that of the control group(P<0.05).Conclusion The enrollment rate of DRGs was significantly correlated with the quality of filling in the front page of inpatient medical records.The implementation of DRGs could improve the timeliness,accuracy and completeness of filling in the front page of inpatient medical records.The implementation of DRGs could effectively improve the quality of medical records and improve the efficiency of diagnosis and treatment.
Rehabilitation medical departmentFront page of inpatient medical recordsGroups related to disease diagnosisApplication effectRelevant measures