摘要
目的分析医院病案首页诊断填写特征,评价干预效果,并提出管理建议。方法以浙江省某综合三级甲等医院2018年和2019年病案首页为研究对象,分析诊断填写特征,针对医师采取病案首页诊断书写的干预并评价效果。对相对权重(RW)与住院天数、住院费用及诊断填写数采用Spearman相关分析;将数据按照季度分类,采用Kruskal-Wallis非参数检验对RW及填写诊断数进行干预前后对比分析。结果RW与住院费用、住院天数及诊断数独立相关。对医生进行诊断书写干预后,其诊疗得到进一步真实表达,RW值也有增高。结论应强化医生病历书写意识,提高诊断填写质量,为疾病诊断相关分组精准运行提供保障。
Objective To analyze the characteristics of diagnosis filling on the home page of medical records,evaluate the intervention effect,and put forward management suggestions.Methods Taking the home pages of medical records of a tertiary hospital in Zhejiang Province in 2018 and 2019 as the research objects,the characteristics of diagnosis filling in were analyzed,and the intervention of diagnosis writing on the home pages of medical records was taken by doctors,and the effect was evaluated.Spearman correlation analysis was used to analyze the relative weight(RW)and the length of stay,hospitalization expenses and the number of diagnosis filled in;the data were classified according to the quarter,and Kruskal-Wallis nonparametric test was used to compare the RW and the number of diagnosis filled in before and after the intervention.Results RW was independently correlated with hospitalization expenses,length of stay and number of diagnoses.After the intervention of doctors′diagnosis writing,the diagnosis and treatment were further truly expressed,and the RW value was also increased.Conclusions It is necessary to strengthen doctors′awareness of medical records writing,improve the quality of filling in diagnosis,and provide guarantee for the accurate operation of diagnosis related groups.
作者
郑盼
郭佳奕
徐敏慧
袁坚列
杜金林
张红怡
Zheng Pan;Guo Jiayi;Xu Minhui;Yuan Jianlie;Du Jinlin;Zhang Hongyi(Affiliated Jinhua Hospital,Zhejiang University School of Medicine,Jinhua 321000,China)
出处
《中华医院管理杂志》
CSCD
北大核心
2020年第12期997-1001,共5页
Chinese Journal of Hospital Administration
基金
浙江省医药卫生科技计划项目(2020KY1011)
金华市科学技术研究计划项目(2019-4-001)。
关键词
病案
首页
相对权重
干预
诊断数
Medical record
Home page
Relative weight
Intervention
Diagnosis number
