As an effective tool for the fine management and medical evaluation of hospitals, DRG has the main data on the first page of medical records, and the quality of the first page of medical records will directly affect the grouping quality and weight calculation of DRG, and then affect the payment and performance evaluation.
So what is a homepage? The first page of the medical record is the use of words, symbols, numbers and other methods by medical staff to concisely summarize the relevant information of the patient during hospitalization in a specific ** to form a summary of case data, which can be said to be the first page of the medical record is the essence of the medical record.
According to the requirements of the Data Quality Management and Control Index of the Home Page of Inpatient Medical Records (2016 Edition), there are 76 items on the home page of the medical record that are required, of which 27 are hospitalization information, 22 are diagnosis and treatment information, 25 are patient information, and 2 are cost information.
Analysis of common quality problems on the first page of medical records
1.Diagnosing the wrong selection
According to the analysis of the actual situation filled in the first page of the medical record at this stage, most medical staff are prone to take the patient's admission diagnosis as the main diagnosis, resulting in information error. At the same time, it is extremely easy for healthcare professionals to overlook some of the complications. For example, a patient who was initially diagnosed with chronic bronchitis developed symptoms such as emphysema and respiratory failure during hospitalization, and the medical staff did not document these complications in a timely manner.
2.Diagnosis is not properly written
For the writing of patients' disease diagnosis, the traditional medical record is mainly written according to the hospital's medical experience and habits, which usually has certain limitations, resulting in its own lack of standardization and imperfection, and obviously cannot meet the requirements.
3.The writing of surgery and operation is not standardized
On the one hand, the actual operation of surgical design is not standardized, and the description of surgical type and surgical method is not accurate enough. In DRG, even if the diagnosis is the same, the ** method will be divided into different DRG groups, that is, the operation group, and the drug ** group. The choice of major surgeries and procedures is important when grouping according to the relevant ** method. In the past, the definitions and standards of major surgeries and procedures were not emphasized, and clinicians did not fill in the form of either the procedure. Surgical and operative items are often incomplete, especially diagnostic procedures, and clinicians have little concept of filling in. As a result, the main operation and operation are incorrect, and a large amount of general operation and operation information is lost, and it is impossible to truly understand all the clinical diagnosis and treatment; On the other hand, with the continuous development of medical technology, there are more and more clinical examination methods, but some physicians usually pay insufficient attention to examination due to some objective factors, which makes there is a certain degree of misfilling and omission in the first page of the medical record.
4.The disease is incorrectly coded
In the process of continuous advancement of hospital informatization, automatic generation of disease codes has become a widely used method in most hospitals. However, some physicians are not familiar with coding and are not able to correct incorrect it in a timely manner. At the same time, some coders' own attitudes and professional problems will also lead to coding errors.
5.Other aspects of the problem
In the face of some critical and serious cases, it is very likely that due to the suddenness of the incident, the medical staff will not be able to accurately fill in the specific information of the patient, especially for basic information such as name and age. In the later stage, the relevant content was not changed in time, resulting in many problems in the later grouping.
How to improve the quality of medical records
There are several key points to do a good job in the quality of medical record data.
First, encoding mapping and conversion are necessary preparations. In order to ensure consistent standards, accurate grouping, and comparable results, medical institutions must carry out coding mapping and convert the homepage coding data according to medical insurance requirements.
The second is to clarify the responsibilities of the personnel who fill in the homepage. The home page of the inpatient medical record includes a total of 116 items in four modules: basic patient information, hospitalization process information, diagnosis and treatment information, and cost information.
The third is to strengthen the training of clinical departments. Clinicians know more about the specific conditions of a patient's medical records than a medical record coder, and their clinical expertise is unmatched by a coder, so the clinician knows more about the patient's disease diagnosis and the actual surgical operations performed than the coder.
Fourth, pay attention to the training and reserve of coders. At the same time, as the final "gatekeeper" of the data on the home page of the medical record, the coder must strictly abide by the coding principles, and can neither under-compile or omit the interests of the hospital, nor can the high-editor be suspected of insurance fraud.
The medical record management department continuously improves the data quality of the first page of the medical record through the training of filling in the homepage of the clinical department and the strengthening of the construction of the teamof coders in the department.
The first page of the medical record quality PDCA
The PDCA cycle, also known as the Deming ring, was proposed by Dr. Deming, an American quality management expert, and is a set of standardized and scientific cycle management systems widely used in quality control, mainly including: plan planning stage; DO Execution Phase; check the inspection stage; In the action summary processing stage, the whole cycle process can be subdivided into 6 links: analyzing the current situation, finding problems, analyzing the causes, determining the goal, implementing the method, and verifying the implementation effect.
(1) Planning stage (p):The personnel of the medical record room were selected to inspect the cases that did not implement the PDCA cycle management method, and the cases with abnormalities and errors were screened, and special personnel were organized to analyze the problems. Through the establishment of a medical record information system, the quality control office, the medical department and various clinical departments are jointly integrated to strengthen management.
(2) Implementation phase (d):Establish a first-class medical record quality control process, led by the vice president in charge of business, establish a medical record management committee, and serve as the director of the committee, the chief of the medical education section as the deputy director, and the director of the clinical department and the medical record statistics department as the member to lead and coordinate the medical record management of the whole hospital.
According to the relevant plans and goals, strictly implement the relevant policy requirements, improve the medical record management system, and standardize the filling of medical records. Hospitals can conduct pre-job training for doctors, standardize the filling of medical records by medical staff, and let medical staff realize the impact of the quality of the first page of medical records on medical record data and DGRS payment, and improve the attention of medical staff. At the same time, it strengthens the learning of professional skills, especially some clinical knowledge in the coding process, so that departments and doctors can take the initiative to carry out quality control of the first page of medical records and the connotation of medical records, and reduce the mistakes of the first page of medical records.
Further strengthen the reduction of the medical record information system, and unify the HIS system, the electronic medical record system and the dictionary database of the medical record statistical management system to eliminate problems such as confusion in information correspondence and errors in the import of information; The introduction of the medical record home verification system, the verification function is embedded in the admission registration system and electronic medical record system, and the accuracy, completeness and logical rationality of the home page information are controlled at the data source.
Strengthen the training of various departments of the hospital, organize the staff of each department to continuously improve their comprehensive quality through relevant special meetings, centralized training and other forms, understand and master the use and content of the PDCA cycle method, and promote the relevant employees to use it proficiently.
Improve the quality of coders and strengthen communication with clinicians, because the clinical knowledge of some case management personnel is not high enough, it is inevitable that inaccurate coding will occur in the face of incurable diseases in the coding process. Therefore, it is necessary to strengthen the communication between medical record managers and clinicians to ensure that medical record managers can better communicate with clinicians when they encounter problems, and further improve the overall quality and accuracy of ICD coding.
(3) Inspection stage (c):The code of the disease is checked by the computer, and the inconsistent entries are summarized and the corresponding report is established, and then the coder checks and modifies it. The quality control team of the Medical Record Statistics Department has been established, which is mainly responsible for the daily supervision and management of the coding quality of the coders, and regularly summarizes and submits the "Evaluation and Feedback" form to optimize the review of the first page of the medical records, the coding process and the work efficiency of the coders. And the establishment of a self-inspection and mutual inspection team, each group members at the end of the month by taking turns to check the code of the record of the code, such as the problem should be recorded and negotiated to solve, the recorded problems are summarized, and regularly reported.
(4) Processing stage (a):Through the results of the inspection, the problems are totaled, and whether the expected goals have been achieved through improvement, and the unresolved problems and emerging problems are re-formulated and re-targeted, and the next PDCA cycle is entered.
* |DRG School, The First Affiliated Hospital of Harbin Medical University.
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