摘要
目的分析歧义病案发生原因,制定有效改进措施,以减少歧义病案的发生,从而提高住院病案首页编码质量及DRG付费的支付标准。方法通过菏泽市CHS-DRG医保支付平台中查询某三级医院2021年7月1日-2021年12月31日期间543份歧义病案,组织临床医师及病案专家查阅电子病历、手术记录、住院病案首页诊断和手术选择原则、DRG分组规则等,分析歧义病案原因。结果543份歧义病案中,主要诊断和手术编码填写错误236份、转科治疗两种以上疾病造成歧义11份、DRG分组规则原因296份。其中236份诊断手术编码填写错误中主要诊断填写错误147份,主要手术操作填写错误77份,主要诊断与主要手术操作均错误12份。结论歧义病案填写错误最常见的是主要诊断和主要手术操作性错误,应加强诊断和手术规范选择知识的培训。
Objectives To analyze the causes of ambiguous medical records,and work out improvement measures to reduce ambiguous medical records,so as to improve the coding quality of the front pages’information of discharge medical records and the payment standard of DRG payment.Methods Through the medical insurance payment platform CHS-DRG in Heze city,543 ambiguous medical records in a tertiary hospital from July 1st,2021 to December 31st,2021 were searched,and clinicians and medical records experts were organized to consult electronic medical records,surgical records,the principles of diagnosis and surgical selection on the front page of inpatient medical records,and DRG group rules,etc.,to analyze the causes of ambiguous medical records.Results Among 543 ambiguous medical records,236 cases were filled in wrong surgical codes,11 cases were transferred to two or more diseases,and 296 cases were caused by DRG grouping rules.Among the 236 diagnostic surgical code filling errors,147 were the main diagnosis errors,77 were the main surgical operation errors,and 12 were both the main diagnosis and the main surgical operation errors.Conclusions The main causes of the ambiguous medical records were choosing the main diagnosis and the main operation,improvement measures should strengthen training of standard choosing the diagnosis and the operations.
作者
薛景勇
任杏
李桂英
Xue Jingyong;Ren Xing;Li Guiying(The People's Hospital of HeZe Mudan,HeZe 274000,ShanDong Province,China;不详)
出处
《中国病案》
2023年第8期15-17,共3页
Chinese Medical Record
关键词
歧义病案
住院病案首页
DRG
Ambiguous medical records
The front page information of discharge medical records
DRG
