以DRGs理论为基础的规范编码及病历书写效果

Canonical Coding Based on DRGs Theory and the Effect of Writing Medical Records

目的探讨以疾病诊断相关组(DRGs)理论为基础进行规范编码提高病历书写质量的效果。方法收集我院2015年度、2016年度各500份病历进行研究,2015年未实施以DRGs理论为基础的规范编码,2016年实施以DRGs理论为基础的规范编码;比较2015年和2016年病历书写质量及编码问题构成情况。结果2015年病历书写质量问题中主要诊断选择错误、损伤中毒的外因、手术及操作书写不规范、病理诊断未填写、手术切口及愈合等级填写错误、手术及操作选择错误、疾病诊断不完整、其他诊断、手术及操作漏写等病历书写质量问题错误率均高于2016年,差异有统计学意义(P<0.05)。2015年病历编码问题中主要诊断编码错误、其他手术错编或漏编、手术及操作编码错误、损伤中毒外因、病理诊断编码错编或漏编、主要诊断编码错误、其他诊断错编或漏编等编码问题错误率均高于2016年,差异有统计学意义(P<0.05);2015和2016年手术切口及愈合等级编写错误发生率比较,差异无统计学意义(P>0.05)。结论以DRGs理论为基础的规范编码及病历书写质量效果较好,有助于降低各类病历书写错误率和编码错误率。

Objective To explore the effect of standardized coding based on the theory of disease diagnosis related groups(DRGs)to improve the quality of medical record writing.Methods Collected 500 medical records of 2015 and 2016 in our hospital for research.In 2015,no standardized coding based on DRGs theory was implemented.In 2016,standardized coding based on DRGs theory was implemented.The quality of medical record writing in 2015 and 2016 was compared.What constitutes a coding problem.Results In the 2015 medical record writing quality problems,the main diagnostic choices were wrong,the external causes of injury and poisoning,surgery and operation writing were not standardized,the pathological diagnosis was not filled,the surgical incision and healing level were incorrectly filled,the operation and operation selection was incorrect,the disease diagnosis was incomplete,and other diagnoses The error rate of medical record writing quality problems such as surgery,operation and missed writing was higher than that in 2016,the difference was statistically significant(P<0.05).Major medical coding errors in 2015,misdiagnosis or omission of other surgery,coding errors in surgery and operation,external causes of injury poisoning,miscoding or omission of pathological diagnostic codes,wrong coding of main diagnosis,miscoding or omission of other diagnosis The error rate of other coding problems was higher than that in 2016,the difference was statistically significant(P<0.05).There was no significant difference in the incidence of surgical incision and healing grade writing errors between 2015 and 2016(P>0.05).Conclusion The standard coding based on DRGs theory and the quality of medical record writing are better,which helps to reduce the error rate of writing quality problems and coding error rates of various medical records.