病案首页质量与DRGS实施

DRGs付费标准依据病案首页内容而制订。目前病案首页填写存在着患者信息采集不完整、不准确;主要诊断及出院情况选择错误;手术、操作填写不规范;以及疾病和手术操作分类错误等问题,这些不同程度地影响DRGs付费的正确实施,影响医保部门对医院的合理付费。通过强化医务人员的责任心及质量意识、发挥相关部门的职能监督作用、完善和提高计算机系统的监控力度、健全沟通反馈制度、培养满足病案信息化管理的综合型人才等措施,能实现病案首页的规范填写,积极应对DRGs付费的需要。

The Quality of Medical Records Front Page and the Implement of DRGs

DRGs payment standards are worked out according to the content of front page of medical records.At present,the filling of medical records front page still exists problems like incomplete and incorrect collection of patients’ information;wrong choose of major diagnosis and hospitalization situation;non-standard filling of surgery and operation and wrong classification of diseases,surgeries and operations,which affects the correct implement of DRGs payment and reasonable payment of medical insurance institutes to hospitals at different degrees.It can achieve standard filling of medical records front page and positively cope with the requirements of DRGs payment by strengthening the responsibilities and quality consciousness of medical staffs,playing functional supervision role of related departments,perfecting and improving monitoring strength of computer system,perfecting communication feedback system and training required comprehensive talents of informationization management of medical records.