Effect of medical record filing management on disease diagnosis related groups and quality of the first page of medical records

Yang Yanmei

doi:10.3969/j.issn.1006-5253.2019.03.023

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Chinese Journal of Hospital Statistics ›› 2019, Vol. 26 ›› Issue (3) : 239-240. DOI: 10.3969/j.issn.1006-5253.2019.03.023

Effect of medical record filing management on disease diagnosis related groups and quality of the first page of medical records

Yang Yanmei

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Abstract

Objective To explore the measures to improve the filing rate of 3 working days of common medical records and 7 working days of death medical records, and the influence on the related grouping of disease diagnosis (DGRs) and its ability index.Methods Data of 82 770 discharged medical records from January to December 2015 and 85 451 discharged medical records from January to December 2017 were randomly derived from our hospital's electronic medical record system. The measures of medical record archiving management were formally implemented in January 2017. The archiving rate before and after the implementation of medical record archiving measures, and the data of DRGs related indicators were statistically analyzed. And the quality of the front page of medical records was analyzed.Results The timely filing rate of medical records was 67.46% in 2015, 93.59% in 2017, and 78.3% in DRGs group increased to 98.4%. There was statistical significance in data comparison (P<0.05). The defect rate of the front page of medical records decreased from 39.49% to 9.31%. There was statistical significance for the comparison (χ ²= 20 455.24, P<0.05). CMI increased from 0.83 to 1.24.Conclusion The establishment of effective medical record management system and reward and punishment system is an effective measure to improve the efficiency of medical record filing, improve the quality of the front page of medical records, and have a positive significance for DRGs.

Key words

medical record filing / measures / DRGs / quality of home page of medical records

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Yang Yanmei. Effect of medical record filing management on disease diagnosis related groups and quality of the first page of medical records[J]. Chinese Journal of Hospital Statistics, 2019, 26(3): 239-240 https://doi.org/10.3969/j.issn.1006-5253.2019.03.023