基于DRGs付款下高倍率病例的病案首页诊断与手术操作填写和编码缺陷分析

Diagnosis and operation filling and coding defect of the first page of high rate paying cases based on DRGs payment

目的 分析某医院基于DRGs付费下高倍率病例的病案首页数据填报中存在的缺陷问题,提出改进对策,避免医院经济损失.方法 某医院从市社保局反馈回来的结算日期为2018年1月至6月经DRGs分组为高倍率病例,依据卫计委下发的诊断手术选择标准、国际疾病分类原则为指导,结合DRGs付费方式,进行自查自纠与回顾性分析,并以6份高倍率病案为例,对缺陷问题进行归类统计.结果 526份高倍率病案中有111份存在缺陷问题,缺陷率21.11%.其中临床医师'主要诊断选择错误'、'主要手术选择错误'、'主诊断和主手术选择错误'、'诊断或手术操作漏填'分别为47份、20份、12份、29份,错误占比分别为42.34%,18.02%,10.81%,26.13%;编码员'主诊断编码错误'、'主手术编码错误'分别为2份、1份,错误占比分别为1.8%,0.9%.结论 病案首页诊断与手术操作填写和编码缺陷问题导致的高倍率病例,与临床医师填写质量、编码员编码水平密切相关.培训临床医师正确选择诊断与手术操作、提高编码员专业技能,优化编码员工作,是减少缺陷问题导致的高倍率病例有效措施.

Objective To analyze the defective problems existing in the data filling in the front page of medical records of the high rate cases whose cost were more than twice the average cost based on DRGs payment in a hospital,and to put forward improvement measures.Methods The hospital received the high rate cases which were grouped by DRGs and settled expenses between January,2018 and June,2018 from the Social Security Bureau's feedback.Combined with DRGs payment mode,under the guidance of the diagnosis operation selection standard announced by the Health Development Planning Commission and the Principles of International Classification of Diseases,self-check and retrospective analysis were conducted,and the defects were classified and counted with 6 cases of high rate paying.Results Totally 111 of 526 high rate cases had defect problems related to clinicians and coders,with defective rate 21.11%,and among them,47,20,12 and 29 cases were clinicians'main diagnostic error selection,main operation error selection,main diagnosis and operation error selection,and missing of diagnosis or operation,respectively.The percentage of errors was 42.34%,18.02%,10.81%and 26.13%respectively.The coders'main diagnosis coding error and main surgical coding error were 2 and 1 cases respectively,with error rate 1.8%and 0.9%respectively.Conclusion The high rate paying cases caused by the defects of the filling diagnosis and operation and the coding defects on the front page of medical records were closely related to the quality of filling by clinicians and the coding level of coders.Effective measures are to train clinicians to correctly select diagnosis and operation,improve coders'professional skills,and optimize coders'work,so as to reduce high rate cases caused by defective problems.