本文已被：浏览 3673次 下载 0次
中文摘要: 目的 探索疾病诊断相关分组（DRGs）应用中歧义病案产生的危险因素。方法 以郑州人民医院2016年1月—2017年12月病案管理中根据主要诊断、主要手术选择筛选出100份歧义病案（实验组）和100份非歧义病案（对照组）为研究对象，对比两组的年龄、住院时间和并发症发生率等。结果 实验组患者的年龄高于对照组，住院时间长于对照组（P＜0.05）；且实验组患者的男性比例、转科比例、出院科别为内科比例、患肿瘤比例及出现并发症比例均高于对照组患者（P＜0.05）；死亡率对比两组差异不明显（P＞0.05）；多因素回归分析发现：高龄、住院时间长、转科、出院科别为内科、患肿瘤和出现并发症均是影响到歧义病案出现的危险因素（P＜0.05）。结论 歧义病案的产生与年龄、住院时间、转科、出院科别、患肿瘤和出现并发症密切相关，医院病案管理可根据歧义病案产生的危险因素制定相应的防治对策，加强病案质量管理。
Abstract:Objective To explore the risk factors of ambiguous medical records in the application of DRGs. Methods 100 ambiguous medical records (experimental group) and 100 non-ambiguous medical records (control group) were screened out from January 2016 to December 2017 in target hospital according to the main diagnosis and surgical selection（P＜0.05). The age, length of stay and complication rate of these two groups were compared. Results The age of the patients in the experimental group was higher than the control group, and the length of stay in the experimental group was longer than the control group; and the proportion of male, transferred, discharged from the medical department, cancer and complications in the experimental group were higher than the control group (P＜0.05); there was no significant difference in mortality between the two groups. Multivariate regression analysis showed that the risk factors affecting ambiguous medical records were old age, long hospitalization time, transferto medical department and discharge department, respectively, internal medicine, cancer and complications(P＜0.05). Conclusion The emergence of ambiguous medical records was closely related to age, length of stay, transfer, discharged department, cancer and complications. Hospital medical records management could formulate corresponding prevention and control measures according to the risk factors of ambiguous medical records, and strengthen the quality management of medical records.
文章编号：3201912025 中图分类号：R44 文献标志码：
基金项目:
| 作者 | 单位 |
| 柴静静① |
| Author Name | Affiliation |
引用文本：