Analysis of Quality Defects on the Home Page of Low-Magnification Medical Recordsin the Environment of DRGs
DRGs环境下低倍率病案首页质量缺陷分析

摘要

目的 分析某医院低倍率病案在首页中的缺陷，对存在的问题提出改进措施。方法 某医院从市社保局经DRGs分组后结算时间为2021年7月到12月入组为低倍率病历486份，按结算时间排序后用等距随机抽样方法共抽162份病案，进行自查自纠和回顾性分析。结果 162份病案中有66份缺陷,其中医生“主诊断错填错选”“主手术错填错选”“主诊断和手术错填错选”“其他诊断或手术错填漏填” ，占比依次为31.82%、6.06%、6.06%、7.57%；编码员“主诊断错编”“主手术错编”“主诊断和手术错编”“其他诊断或手术错编漏编”占比依次为19.70%、13.64%、6.06%、9.09%；结论 医院应提高医生填写诊断和手术操作要求、培训ICD和DRGs知识；提高编码员的编码水平、工作责任心及态度进而提高ICD编码准确性。

Abstract

Objective To analyze the defects in the homepage of a hospital's low-rate medical records, and to propose improvement measures for the existing problems.
Methods A hospital was grouped by DRGs from the Municipal Social Security Bureau and enrolled 486 low-rate medical records from July to December 2021. A total of 162 medical records were selected by the equidistant random sampling method for self-examination. Self-correction and retrospective analysis.
Results There were 66 defects in the 162 medical records, among which the doctors "wrongly filled in the wrong choice for the main diagnosis", "wrongly filled in the wrong choice for the main surgery", "wrongly filled in the wrong choice for the main diagnosis and operation", "wrongly filled in the wrong filling in the other diagnosis or surgery", accounting for The ratios were 31.82%, 6.06%, 6.06%, and 7.57% in sequence; the proportions of coders in the order of "wrong coding of main diagnosis", "wrong coding of main surgery", "wrong coding of main diagnosis and surgery", "miscoding of other diagnoses or surgery", etc. The percentages were 19.70%, 13.64%, 6.06%, and 9.09%;
Conclusion   Hospitals should improve doctors to fill in the requirements for diagnosis and surgical operation, train ICD and DRGs knowledge; improve the coding level, work responsibility and attitude of coders to improve the accuracy of ICD coding.