病案未入疾病诊断相关组原因探究

Study on the characteristics of medical records not enrolled in diagnosis related groups(DRGs)

目的:提升病案首页填报质量,从而提高病案DRGs入组率。方法:利用文献研究以及回顾性研究方法对某院2019年111份未入DRGs组病案进行分析,找出未入组的原因。结果:文献研究中主要诊断与主要手术或操作编码填写错误,分组器系统问题和病案首页填写的完整性等影响病案能否入组。某院研究的111例未入组病案中新生儿年龄问题48例,系统问题30例,主要诊断与主要手术、操作编码或填写问题28例,转科、会诊原因5例。讨论:提高编码员编码水平,加强临床医师病案首页填写能力,分组器不断根据临床实际问题进行升级,首页输入系统增加逻辑校验功能可有效提高病案入组率。

Objective:To improve the quality of filling in the first page of medical records so as to increase the DRGs enrollment rate of medical records.Methods:The literature research and retrospective research methods were used to analyze 111 cases of DRGs that were not enrolled in a hospital in 2019 to find out the reasons for not enrolling.Results:In the literature research,the main diagnosis and main operation or operation coding or filling errors,grouper system problems,and the completeness of the front page of the medical records affect the ability to enter the medical records.Among 111 cases not studied in a hospital,there were 48 cases of neonatal age problems,30 cases of systemic problems,28 cases of main diagnosis and major surgical coding or filling out problems,and 5 cases of transfer and consultation.Discussion:Improve the coding level of the coder,strengthen the ability to fill in the first page of the clinician’s medical records,the grouper is constantly upgraded according to clinical actual problems,and the logical input function of the homepage input system can effectively improve the medical records enrollment rate.