Construction and application of the quality control system for medical record home page based on CHS-DRG grouper
10.3760/cma.j.cn111325-20240910-00772
- VernacularTitle:基于CHS-DRG分组器的病案首页质控系统构建及应用
- Author:
Yi PEI
1
;
Yi HE
;
Cunjian NAI
Author Information
1. 华中科技大学同济医学院附属同济医院病案科，武汉 430030
- Publication Type:Journal Article
- Keywords:
Medical record;
Quality control;
Diagnosis related group;
Management information systems;
Human-machine cooperation
- From:
Chinese Journal of Hospital Administration
2025;41(5):360-365
- CountryChina
- Language:Chinese
-
Abstract:
With the advancement of high-quality development in the healthcare system, the quality of the home page of medical records has become increasingly prominent, as an important data source for hospital management, performance evaluation, and medical insurance payment. In 2022, a grade-A tertiary hospital took improving the quality of the main diagnosis and surgical operations related data on the home page of medical records as the core goal, and constructed a quality control system for the home page of inpatient medical records based on the national medical security disease diagnosis-related groups (CHS-DRG). This system included two parts: the CHS-DRG grouper and early warning rules for high-risk medical records, which could issue warnings for abnormal data in the grouping results. Then, based on this system, a human-machine collaborative quality control mechanism for the home page of medical records, namely " system warning-coder review-communication between coders and clinical doctors", was established and applied since January 2022, realizing closed-loop management of quality control for the home page of medical records. Compared with 2020-2021, the accuracy rates of main diagnosis filling, main surgeries filling, and main diagnosis coding in 2022-2023 increased by 16.31, 12.45, and 1.70 percentage points respectively ( P<0.05); the number of diagnosis items increased by 0.91 ( P<0.05), and the coding time consumption decreased by 4.59 d ( P<0.05). Meanwhile, after the application, the quality improvement effect on the non-DRG payment group was higher than that on the DRG payment group ( P<0.05). The application of this system not only helps to improve the information-based means of medical record quality control and enrich the method system of medical record quality control, but also comprehensively improves the quality and work efficiency of the home page of medical records under different payment methods, which can provide reference for other hospitals to continuously improve the quality control work of the home page of medical records.
