DRG支付方式改革下歧义病案分析及改进措施探讨

Exploration of ambiguous medical record analysis and improvement measures under DRG payment system

目的在DRG支付方式改革下,分析某三甲医院歧义病案首页中主要诊断与主要手术操作选择存在的问题并探讨改进措施,以提高DRG入组率,使病案首页的数据质量得到持续改进。方法对市医保数据平台反馈的2021—2022年6月883份歧义病案逐份回顾性审核并进行修正分析。结果883份歧义病案分布37个临床科室,其中内科占48.1%、外科占34.0%。临床医师错误占78.94%,编码员错误占7.59%,临床医师和编码员均错占2.27%,分组器不完善导致的歧义病案占11.21%。结论临床医师未掌握医保结算清单诊断和手术操作选择原则,编码员临床知识及编码规则掌握不够,分组器不完善是产生歧义病案的主要原因。应强化临床医师的培训及反馈、提高病案编码员业务水平、加强病案首页质控、增进与医保部门沟通反馈,提高病案首页数据质量,降低歧义病案率的发生。

Objective To analyze the problems in the selection of main diagnosis and main surgical operations on the front page of ambiguous medical records in a large hospital,and to explore the improvement measures,so as to improve the enrollment rate of DRG and the quality on the front page of medical records under the reform of DRGs-PPS.Methods A total of 883 ambiguous medical records from 2021 to June 2022 were reviewed and corrected,which were reported by the medical insurance data platform.Results 833 ambiguous medical records were distributed in 37 clinical departments,of which internal medicine accounted for 48.1%and surgery 34.0%.The errors of clinicians accounted for 78.94%,the errors of coders accounted for 7.59%,the errors of clinicians and coders accounted for 2.27%,the errors caused by imperfect grouping device accounted for 11.21%.Conclusion The main reasons for ambiguous medical records are that clinicians do not master the main diagnosis and operation selection principles on the medical insurance settlement statement,coders have weak clinical knowledge,coding rules are not mastered enough,and the grouping device is not perfect.We should strengthen the training of clinicians,improve the professional level of coders,strengthen the quality control of the front page of medical records,enhance communication and feedback with the medical insurance department,so as to improve the data quality of the front page of medical records and reduce the occurrence of ambiguous medical records.