摘要
目的根据某院关于国家医疗保障疾病诊断相关分组CHS-DRGs(China Healthcare Security Diagnosis Related Groups,CHS-DRGs)分组异常病案中,分析主要诊断为恶性肿瘤的病例中存在的问题,提出改进措施,持续提升编码数据质量,提高入组准确率。方法从某院实施CHS-DRGs分组半年来(2022年1—6月)反馈的情况,回顾性分析入组异常病例,抽取主要诊断国际疾病与相关健康问题统计分类第10版(the international statistical classification of diseases and related health problems 10th revision,ICD10)为C00-C97、Z51的患者51份进行分析。结果经过分析发现51份入组异常病案,临床医师主要诊断选择错误22例,主要手术选择错误7例,主要诊断编码错误的有1例,主要手术编码错误的8例,疾病诊断相关分组(diagnosis related groups,DRGs)分组方案缺陷的有13份。结论DRGs入组异常病案是由临床医师病案首页填写及编码员能力问题造成。应开展病案首页的专项质控,督促临床医师规范填写病案首页出院诊断名称,编码员正确编码,确保病案首页数据和DRGs分组数据的准确性。
Objective According to the hospital's CHS-DRGs(China Healthcare Security Diagnosis Related Groups)grouping related to national medical security disease diagnosis,analyze the problems in the cases mainly diagnosed as malignant tumors,propose improvement measures,continuously improve the quality of coding data,and improve the accuracy of enrollment.Methods Based on the feedback from the implementation of CHS-DRGs grouping in a hospital for half a year(January 2022 to June 2022),51 patients with major diagnoses of International Statistical Classification of Diseases and Related Health Problems(the tenth edition)as C00-C97 and Z51 were selected for analysis.Results Through analysis,a total of 51 cases of abnormal medical records were found to be included in the group.Among them,22 cases were diagnosed incorrectly by clinicians,7 cases were selected incorrectly for major surgery,1 case was coded incorrectly for major diagnosis,8 cases were coded incorrectly for major surgery,13 cases of defect in grouping scheme of diagnosis related Groups(DRGs).Conclusion The abnormal medical record of DRGs was caused by the problem of filling in the first page of the medical record of the clinician and the ability of the coder.Special quality control should be carried out on the first page of the medical record,and clinicians should be urged to fill in the discharge diagnosis name on the first page of the medical record in a standardized manner.The coder should code correctly to ensure the accuracy of the data on the first page of the medical record and DRGs grouping data.
作者
郑锦瑛
林琦
陈敏惠
吴秀桦
ZHENG Jinying;LIN Qi;CHEN Minhui;WU Xiuhua(Department of Medical Record,Changle District Hospital,Fuzhou City,Fuzhou Fujian 350200,China;Medical Record Statistics Office,Fujian Medical University Union Hospital,Fuzhou Fujian 350000,China)
出处
《中国卫生标准管理》
2023年第4期11-15,共5页
China Health Standard Management
关键词
CHS-DRGs
住院病案首页
QY病案
主要诊断
主要手术操作
缺陷分析
编码质量
CHS-DRGs
inpatient medical record front page
QY medical record
main diagnosis
main surgical procedures
defect analysis
coding quality
