病案首页与编码质量对病种付费的影响

目的 探究病案首页与编码质量对病种付费产生的影响.方法 2019年1-12月纳入研究的1056例病案首页均为该院产科、颅脑外科、普通外科、肿瘤科及心外科5个科室所收纳,依照回顾性分析方式进行平均分组,病案首页均经针对性措施解决病案首页问题,并经校对手段质控编码确认无误(试验组,n=528),重新编码前病案首页(对照组,...

The Impact of Medical Record Homepage and Coding Quality on Disease Payment

Objective To explore the impact of the quality of the first page of the medical record and the coding on the payment of the disease.Methods From January to December 2019 the first pages of the 1056 medical records included in the study were all accepted by the five departments of the hospital:Obstetrics,Craniocerebral Surgery,General Surgery,Oncology and Cardiac Surgery.According to retrospective analysis method,the patients were divided into groups averagely.The first page of the medical record is solved by targeted measures,and the quality control code of the proofreading method is confirmed to be correct(experimental group,n=528),and the first page of the medical record before recoding(control group,n=528),analyzed the differences and changes in the two groups of data.Results The quality of payment for disease types in the experimental group including hospital data statistics scores,medical record information utilization scores,disease grouping accuracy scores,and hospital economic benefit score evaluations were significantly higher than those in the control group.The content of medical records in the experimental group did not match the medical record homepage,and the diagnosis was omitted.The incidence of adverse events of incomplete diagnosis and incorrect diagnosis of medical records was significantly lower than that of the control group.The incidence of missing and incorrectly filled defects in the test group was significantly lower than that of the control group.The data difference between the groups was statistically significant(P<0.05).Conclusion Analyze the quality of the medical record homepage,analyze the factors that affect the medical record homepage,and make targeted improvements,which will help improve the quality of medical records and reduce the adverse effects of the quality of medical records and coding on disease payment.