摘要
目的据某三甲医院DRG分组未入组病案存在的问题,分析疾病性质对手术编码的影响,提出解决对策,持续改进提高病案数据质量。方法对病案室2022年1—6月上报DRG分组后的病案,经DRG住院医疗服务检测与分析系统数据中心平台查找出其中因为手术操作名称中疾病性质因素使得该病历不被纳入DRG组的例数,对其缺陷问题进行举例、归类、统计和分析,以及修正手术编码的费用前后统计分析,并探讨解决措施。结果经过统计分析发现,377份未入组病案产生的原因与主要诊断和手术操作等有关占85.46%。主要诊断与手术操作中因疾病性质原因造成手术操作编码不匹配55份。结论未入组病案的问题实质上就是主要诊断中的疾病性质和手术操作的问题。病案信息管理者应加强病案书写管理和培训方法,提升病案疾病诊断书写能力,确保病案首页数据和DRG分组数据的准确性,提高入组率。
Objective Based on the problems existing in the DRG grouping of non-enrolled medical records in a tertiary hospital,analyze the impact of disease nature on surgical coding,propose solutions,and continuously improve the quality of medical record data.Methods From January to June 2022,the medical records reported to the DRG group in the medical records room were found by the data center platform of the DRG inpatient medical service detection and analysis system,and the number of cases in which the medical records were not included in the DRG group due to the disease nature of the surgical operation name was found,and the defects were cited,classified,counted and analyzed.And the statistical analysis of the cost before and after the revision of the surgical code,and discuss the solution.Results After statistical analysis,it was found that the causes of 377 non enrolled medical records were related to the main diagnosis and surgical procedures,accounting for 85.46%.The main diagnosis and surgical procedures were 55 cases of mismatched surgical procedure codes due to the nature of the disease.Conclusion The issue of not being included in the medical record is essentially a matter of the nature of the disease and surgical procedures in the main diagnosis.Medical record information managers should strengthen the management and training methods of medical record writing,improve their ability to diagnose and write medical records,ensure the accuracy of medical record homepage data and DRG grouping data,and improve enrollment rates.
作者
林佩珊
李良景
任文宁
LIN Peishan;LI Liangjing;REN Wenning(Shenzhen People’s Hospital,The Second Clinical College of Jinan University,The First Affiliated Hospital of Southern University of Science and Technology,Shenzhen 518020,China;School of Information and Management,Guangxi Medical University,Nanning 530000,China)
出处
《现代医院》
2023年第12期1852-1855,1860,共5页
Modern Hospitals
关键词
手术操作
疾病性质
未入组病案
DRG入组率
Surgical procedures
Nature of the disease
Unorganized medical records
DRG enrollment rate
