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| Screening effect of DRGs detection software on the first page of medical records |
| Liu Jiyang1, Shen Yang2 |
1 Medical Record Statistics Department, Xiaogan Central Hospital, Xiaogan 432000, China;
2 Medical Administration Department, Xiaogan Central Hospital, Xiaogan 432000, China |
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Abstract Objective To audit the quality of the first page of hospital medical records by using DRGs hospital analysis and inspection X software, verify the feedback errors by manual inspection, and compare and analyze the screening effect of DRGs testing software on the first page of medical records.Methods The first page data of electronic medical records in the first quarter of 2020, which had not passed quality control, were collected and sorted out, and imported into DRGs grouping system data format for processing. X software was used for error detection and screening, and 200 medical records were sampled randomly. In addition, the audit team set up by the hospital verified 200 sampled wrong medical records one by one, summarized, compared and analyzed the causes of errors. Results Among the 200 wrong medical records screened by X software, 4 were not included in the group. Among the 196 wrong medical records, there were 35 non-coding errors and 161 coding errors. The audit team checked the front pages of the 200 wrong medical records, and found that 7 cases were not included in the group, 30 cases were non-coding errors and 163 cases were coding errors. X software can play an active role in the quality screening of the front pages of medical records, and most of the errors on the front pages of 200 medical records are consistent with the actual situation, but there are still some defects. Conclusion DRGs hospital analysis and testing software can play an active role in screening, and its effect still needs to be constantly updated and improved in practice.
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Received: 06 February 2021
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