【摘要】 目的观察住院医师DRGs知识培训对于其出院病历中主要诊断、主要手术或操作填报正确率的改进效果。方法收集整理实行BJ-DRGs试点的北京某三甲医院住院医师DRGs知识培训后6个月出院病历主要诊断及主要手术或操作填报数据,与上年该医生同期出院病历的主要诊断及主要手术或操作填报情况进行比较,分别计算该医生病案中主要诊断及主要手术或操作填报数据的正确率。结果培训后,住院医师病案中主要诊断和主要手术或操作填报的正确率比上年同期有明显提高。结论对住院医师进行DRGs知识培训能显著提高出院病历主要诊断和主要手术或操作填报的正确性。更多还原

【Abstract】 Objective To investigate the effect of residents’ DRGs knowledge training on their correct rates of primary diagnosis and surgical operation report on discharge medical records. Methods We collected 6-month data of primary diagnosis and major surgery operation on discharge medical records among residents after receiving BJ-DRGs training in a Grade 3 A hospital in Beijing. We then compared these data with the primary diagnosis and major surgery operation on discharge medical records among same residents in the same period of the previous year. We calculated correct rates of primary diagnosis and major surgery operation report after and before the training respectively. Results After training, the correct rates of primary diagnosis and reported major surgery operation on medical records were significantly higher than those of the same period of the previous year. Conclusion The DRGs knowledge training of residents can significantly improve correct rates of primary diagnosis and major surgery operation report on discharge medical records.更多还原