【摘要】 目的 基于疾病诊断相关分组(DRG)与按病种分值付费(DIP)双维度，分析广州某三甲医院2023年出院病历首页质量情况，为提升病案首页质量管理精细化水平提供依据。方法 选取某三级甲等综合医院2023年出院病历，对全量病历进行DRG分组，对实施按病种分值支付的广州市医保和省内异地医保病历进行DIP模拟分组，并分析出院病历的书写缺陷情况，以及首页填写缺陷病历的DRG入组情况、RW和DIP标准分值情况。结果 172 230份出院病历中，DRG入组病历171 786份，DIP入组病历91 768份，同时入组DRG、DIP病历91 604份，RW与DIP标准分值之间呈显著正相关(r~2=0.681,P<0.001);在同时入组DRG、DIP的91 604份病历中，1 942份(2.12%)存在书写缺陷，其中首页缺陷病历837份(0.91%);首页缺陷病历较多的DRG组有NC15、HK2、EJ13、EB15、HJ13和RE19等。结论 病案首页质量缺陷影响DRG和DIP分组准确性，应通过加强病历书写培训、建立科学奖惩机制等系统性措施，为DRG/DIP支付方式改革的深入推进提供数据支撑。更多还原

【Abstract】 Objective To analyze the quality of medical record home pages for discharged patients in a tertiary hospital in Guangzhou in 2023 based on the dual dimensions of Diagnosis-Related Groups( DRG) and Disease Intervention Program( DIP),and to provide a basis for improving the refinement of medical record home page quality management. Methods Discharge medical records from a tertiary general hospital in 2023 were selected. All medical records were grouped using DRG,while medical records under Guangzhou medical insurance and cross-province medical insurance implemented under DIP were simulated for DIP grouping. The writing defects in the discharge medical records were analyzed,as well as the DRG grouping,RW,and DIP standard scores of medical records with home page filling defects. Results Among 172 230 discharge medical records,171 786 were grouped into DRG,91 768 were grouped into DIP,and 91 604 were grouped into both DRG and DIP. A significant positive correlation was found between RW and DIP standard scores( r~2= 0. 681,P < 0. 001). Among the 91 604 medical records grouped into both DRG and DIP,1 942( 2. 12%) had writing defects,including 837( 0. 91%) with home page defects. DRG groups with more home page defect records included NC15,HK2,EJ13,EB15,HJ13,and RE19. Conclusion Quality defects in medical record home pages impact the accuracy of DRG and DIP grouping. Systematic measures such as strengthening medical record writing training and establishing scientific reward and punishment mechanisms should be implemented to provide data support for the further advancement of DRG/DIP payment reform.更多还原