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Objective To establish an adverse event monitoring system in the course of encoding medical record homepages, using the internationally accepted Clavien-Dindo surgical complications grading standard, for the purpose of hospital′s medical safety management. Methods The surgical complications record system was established based on encoded medical record homepages. Data of three types of medical therapies of the discharge cases of a tertiary hospital in 2017 were studied and the incidence, type and grading of the surgical complications were analyzed, to identify doctors′missed diagnoses. Results A total of 588 surgical complications were detected from the discharge cases throughout the year. The incidence of surgical complications was 1.1% (588/52 319). The highest proportions of all surgical complications were infection and surgical incision problems. Grade Ⅱ complications accounted for the highest incidence rate (41.5% , 244/588); the proportion of missed surgical complications at the initial homepage was 62.2% (366/588), most of which being as grade Ⅱ complications ( 42.1% , 154/366). Conclusions The hospital adverse event monitoring system established based on the encoded medical record homepages features unified standard, making it feasible and universal, which serves an important role of the medical adverse event reporting system.
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The healthcare-associated infections (HAI) cases monitoring system, automatic access to the medical record homepage and HAI early warning application of untreated early warning information interception and other means of information are introduced into the hospital. These means ensure the accuracy and integrity of the medical record homepage diagnostic and statistical data base information, and HAI consistency as well. Closed loop management of HAI cases provides accurate information for the hospital business intelligence platform, serving hospital administration and clinical management with accurate data. Hence precise decision-making basis can be provided for the improvement of medical quality of the hospital.
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Objective To explore diagnosis-related groups(DRGs) case mixes and development approaches for medicare expense standard fitting patients with respiratory system diseases in Sichuan province.Methods 280 717 cases of respiratory system diseases were sampled from the homepages of medical records of general hospitals in Sichuan.These cases were grouped by means of the exhaustive chi-square automatic interaction detector in the decision tree model and the medicare costs standard was derived using the relative-ratio weighting coefficient.Results The main classification nodes of respiratory diseases were age and patient clinical complexity level (PCCL).Patients were classified into 158 disease diagnosis related groups, including 122 DRGs of internal medicine and 36 DRGs in surgical medicine.The max relative-ratio weighting coefficient was 14.04 and the min one was 0.29.And the extreme inpatients' expenses can affect the identification of classification nodes, calculation of relative weighting coefficient and medicare cost standard.Conclusions Large sample size is advantageous in establishing DRGs and calculating the medicare costs standard based on relative-ratio weighting coefficient.It is however imperative to strengthen monitoring on extreme inpatients' costs and control the homepage quality of medical records.
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BJ-DRGs grouping process was cited as an example, to describe the factors affecting the grouping process, grouping results and assessment results, and the solutions in transferring homepages into WJT form 4-1 for inpatient medical record homepages (WJT form 4-1 for short).Authors analyzed how to better information acquisition quality of such homepages by unifying the data interface standard of WJT form 4-1, for the purposes of enhancing BJ-DRGs grouping efficiency, and expanding its functions as a tool for medical quality management and that for medical insurance payment management.
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Objective:Study on the clinical application and analysis of structured electronic medical records in our hospital in last.Methods: Discharged patients data selected from July 2012 to June 2014, using statistical methods for data processing, 8000 case files were divided into two groups: Group A and Group B.Results: After comparing the two groups of two groups of data, and ultimately disease coding accuracy rate 94.88%, fill in the correct rate increased 88.38%, missing rate decreased 4.63%, two groups had no significant difference data; The quality of writing the doctor increased gradually, the error rate tends to be stable, structured clinical application to control.Conclusion: Sequential specification writing medical doctor, scientific analysis of medical record information, the clinical application of structured electronic medical records the error rate is reduced in the operation, improve the accuracy, more standardized, accurate, standardized.