Standardizing Diagnosis Writing and Improving DRGs Data Quality

AbstractObjective. In 2013, Beijing medical insurance has achieved total expense pre-payment. The DRGs is one of the important evaluation tools for inpatient payment management; in order to improve the uploading quality of the DRGs data, it is necessary to standardize the writing of the diagnosis in the first page of the medical record. Method. To improve the diagnostic accuracy by strengthening the DRGs knowledge publicity and training, establishing a standardized database of synonyms for diagnostic names, by means of the information network, and using information technology to establish a visual platform for writing the diagnosis. By comparing the DRGs data in our hospital with the data of Beijing in the past two years, the hospital administrators and clinicians can understand where the problem lies in the diagnosis writing and the gap in the grouping of related data between our hospital and the average level of the same at Beijing. Result. The clinicians’ levels of writing the diagnosis and the quality...