摘要
目的分析医院颅内出血错误编码及对DRGs入组影响,提高颅内出血编码准确性。方法利用病案检索系统查找2018年1月1日-2018年12月31日颅内出血病例193份,逐条核对主要诊断、主要手术操作编码,将错误病例修改后进行再次DRG分组,最后对错误内容进行汇总分析。结果错误病例49份,错误率为25.39%;主要诊断错误45例,主要手术操作错误4例。错误最多为脑叶出血错编为未特指的脑出血占比59.18%,其次为主要诊断与治疗经过不匹配占比8.16%;其中10例错误导致DRGs分组差异,创呼吸机漏编导致错分为BY11组,对CMI值影响最大,导致其降低3.01、其次为颅内动脉瘤错编导致错分为BE19组CMI值降低1.56。结论颅内出血主要诊断和主要手术操作填报错误,主要由于编码员编码错误和医师病案首页填写错误造成,编码员应加强编码及临床知识学习,加强于医师沟通,从而提高编码质量及DRG数据准确性。
Objectives To analyze and study the incorrect coding of intracranial hemorrhage in hospitals and its influence on the enrollment of DRGs to improve the accuracy of coding of intracranial hemorrhage.Methods Use the medical record retrieval system to find 193 cases of intracranial hemorrhage from January 1st,2018 to December 31st,2018,check the main diagnosis and main surgical operation codes one by one,modify the wrong cases and perform DRG grouping again,and summarize and analyze the error content.Results There were 49 problematic cases,with an error rate of 25.39%;45 cases were mainly diagnosed errors,and 4 cases were main surgical errors.The most errors were intralobular hemorrhage,which was incorrectly classified as unspecified intracerebral hemorrhage,accounting for 59.18%,followed by the mismatch between the main diagnosis and treatment,which accounted for 8.16%;10 cases of errors resulted in differences in DRGs grouping,and most were missed by invasive ventilator.As a result,it was incorrectly classified into BY11 group,the CMI index decreased by 3.01,and the intracranial aneurysm was incorrectly classified,which resulted in a decrease in CMI value of 1.56 in the BE19 group.Conclusions Intracranial hemorrhage was mainly diagnosed and reported incorrectly in major surgical operations.It was mainly caused by coding errors of coders and errors in filling in the homepage of physicians'medical records.Coders should strengthen coding and clinical knowledge learning,and strengthen communication with physicians,so as to improve the quality of coding and the accuracy of DRG data.
作者
郑博闻
高婕
刘天野
刘辰龙
Zheng Bowen;Gao Jie;Liu Tianye;Liu Chenlong(Department of Medical Record and Statistics,The First Hospital of Peking University,Beijing 100034,China;不详)
出处
《中国病案》
2021年第7期45-48,共4页
Chinese Medical Record
