某医院DRGs未入组病例情况分析

Analysis of Unincorporated Cases of DRGs in a Hospital

目的:分析某院DRGs中未入组病案编码情况,为提高DRGs入组率提供建议。方法:以某肿瘤专科医院2018年1-11月住院病案首页数据为来源,采用回顾性分析从某院DRGs系统检索未入组病案,分析未入组病例的原因、科室分布情况。结果:全院出院病例数65019份,去掉大于60天病例数353份,入组病例数64405份,入组率达99.6%,未入组病例数261份,其中主要诊断编码不在北京临床版范围内146例、手术/操作与主要诊断不符114例,费用异常1例。在科室分布上,外科病例178份,内科病例83份。结论:住院病案首页质量,尤其是主要疾病诊断选择的准确性有待提高。

Objective:To analyze the status of medical records which were unable to be encoded in DRGs system in a hospital,and to provide suggestions for elevating the coding rate of DRGs system. Methods:The front pages of the inpatient medical records were re. viewed in Jiangsu Cancer Hospital from January to November in 2018. The unencoded medical records in DRGs system were selected, and then the reasons and department distribution of unencoded cases were analyzed. Results:The number of discharged patients was 65 019,and 353 cases were deleted due to more-than-60 days inpatient period. The number of encoded cases was 64 405(99.6%), while the number of unencoded cases was 261(0.4%). Of these 261 patients,there were 146 patients with a unencoded main diagnos. tic code,114 cases with a unmatched surgical code and 1 case with fee abnormality. And there were 178 surgical cases and 83 medical cases. Conclusions:The quality of the front page of inpatient medical records,especially the accuracy of main diagnosis,needs to be improved.