DRG入组误入低风险死亡病例组的原因及改善措施研究

Study on the Cause and Improvement Measures of DRG Entering Into Low-risk Death Case Group by Mistake

目的研究探讨对于疾病诊断相关入组(diagnosis related group,DRG)误入组的低风险死亡病例组的具体原因,并提出相应整改措施。方法选取福建医科大学附属协和医院在2019年3—12月之间所接收的30例低风险死亡病例,并进行分析找出具体原因。结果经过观察分析可知,30例中共存在22例误入低风险死亡组,其中13例为住院首页填写不当导致,其中9例为分组器的原因。结论通过加强病案核心制度实施能够更有利于临床开展住院病案首页数据质量评估,同时通过积极开展住院病案首页数据质量培训,积极引入相应的死亡病历编码讨论系统,建立住院病历首页数据智能审计系统,降低低危死亡的病例登记率。

Objective To investigate the specific causes of lowrisk death cases in DRG group by mistake,and to propose corresponding rectification measures.Methods 30 low-risk death cases received by Union Hospital Affiliated to Fujian Medical University from March 2019 to December 2019 were selected and analyzed to find out the specific causes.Results Through observation and analysis,22 of the 30 patients entered the low-risk death group,13 of them were caused by improper filling in the home page of hospitalization,and 9of them were caused by pacers.Conclusion The registration rate of low-risk death cases can be reduced by strengthening the implementation of the core system of medical records,implementing the data quality assessment method of the first page of inpatient medical records,strengthening the data quality training of the first page of inpatient medical records,establishing the coding discussion system of death records,and establishing the intelligent audit system of the first page of inpatient medical records.