基于DRGs理论下消化内科编码质量提升研究

Improvement of gastroenterological coding quality based on DRGs theory

目的按照DRGs的理论要求,分析皖南医学院第一附属医院消化内科疾病诊断、手术编码存在的问题,深入分析其原因并提出改进措施,为DRGs的有效实施奠定基础。方法采取分层抽样的方法抽取2018年1月-2018年12月入住消化内科治疗患者的病案首页资料为数据来源,共1 200份病历。对病案首页中主要诊断编码、其他诊断编码、手术或操作编码情况进行归类、统计分析。结果 1 200份病历中,有565份病历存在编码缺陷,占比47. 08%,对存在编码缺陷的565份住院病案进行核查,发现存在缺陷863条,其中主要诊断有185条缺陷(21. 44%)、其他诊断存在123条缺陷(14. 25%)、手术或操作编码存在缺陷的有555条(64. 31%)。结论疾病诊断、手术操作的编码准确性是DRGs顺利实施的基础,应对各临床科室采取相应措施加强首页编码的质量控制。

Objective To analyze the problems in gastroenterological diagnostic and surgical codes in Yi Jishan Hospital of Wannan Medical College according to the DRGs theory,explore the causes and propose improvement measures,and lay a foundation for effectively implementing DRGs. Methods A total of 1 200 medical records of patients admitted in the gastroenterology department from January 2018 to December 2018 were selected by stratified sampling method. The patients’ information on the first pages of medical records was used as data sources and the main diagnostic codes,the secondary diagnostic codes,the surgery or operation codes on the first pages were classified and statistically analyzed. Results 565 out of the 1 200 medical records showed coding defects,accounting for 47. 08%. Moreover,among the 565 reviewed medical records with coding defects,there were 863 pieces of defective codes,including 185 main diagnostic codes( 21. 44%),123 secondary diagnostic codes( 14. 25%) and 555 surgery or operation codes( 64. 31%). Conclusion Since coding accuracy of disease diagnosis and surgical operation sustains the successful implementation of DRGs,measures should be taken to reinforce the quality control of coding in each clinical department.