摘要
目的通过分析某综合医院脑卒中住院病案编码缺陷及对DRG分组的影响,探讨提高卒中疾病编码准确率和入组正确率的有效措施。方法利用病案检索系统查找2018年1月1日-2021年12月31日主诊编码为I60-I64的病例5137份,逐条核对主要诊断编码与主要手术编码,对错误内容进行汇总分析,并在修改后运用分组器重新进行DRGs分组,分析修改前后分组差别。结果累计编码错误病例1998份,错误率为38.89%。导致主要诊断与主要手术编码错误的主要原因为医师填写错误,共1287份;其次为编码员录入错误,共711份。主要诊断编码选择错误造成ADRG组有区别的病例共123份。主要手术编码选择错误造成ADRG组有区别的共18例。结论部分脑卒中编码错误会造成DRG分组错误,编码正确是DRG分组正确的基础。医院应当依据不同科室不同病种对医师和编码员进行培训和考核,以提高编码准确性。
Objectives By analyzing the coding defects of stroke inpatient records in a general hospital and their impact on DRG grouping,this paper aims to explore effective measures to improve the accuracy of stroke disease coding and enrollment.Methods The medical record retrieval system was used to find 5137 cases with the codes I60-I64 from January 1,2018 to December 31,2021.The main diagnostic codes and main surgical codes were checked one by one.The error content was summarized and analyzed.After the modification,the grouper was used to regroup the DRGs,and the grouping differences were analyzed before and after the modification.Results A total of 1998 cases were coded incorrectly,with an error rate of 38.89%.The main reason for the coding errors of major diagnoses and major operations was that physicians filled in errors,a total of 1287 cases,followed by coder input errors,a total of 711 copies.A total of 123 cases had differences in the ADRG group due to the wrong selection of the main diagnostic codes.A total of 18 cases had differences in the ADRG group due to the wrong selection of the main operation code.Conclusions Some stroke coding errors will cause DRGs to be grouped incorrectly,and correct coding is the basis for correct DRG grouping.Hospitals should train and assess physicians and coders based on different diseases in different departments to improve coding accuracy.
作者
张钰璐
王瑞宇
何俊曦
王靖
何作顺
Zhang Yulu;Wang Ruiyu;He Junxi;Wang Jing;He Zuoshun(College of Public Health,Dali University,Dali 671000,China;不详)
出处
《中国病案》
2023年第5期10-13,共4页
Chinese Medical Record
基金
2020年大理市科技项目计划任务书(2020KGB063)。
