2472份眼科住院病案首页编码质量对DRGs分组影响

Influence of the Coding Quality of the First Page of 2472 Ophthalmic Inpatient Records on the DRGs

目的通过分析某综合医院眼科诊断和手术操作编码及其DRGs入组的情况,针对住院病案首页质量情况提出改善措施。方法收集2017年1月1日~2017年12月31日出院的眼科住院病案2472份,以问题为导向对住院病案首页进行质控,将错误情况记录,修正ICD-10编码后重新入组统计汇总。结果眼科住院病案首页主要诊断和手术操作错误1079份,占43.65%。对分组产生影响的有24份,占问题病案的2.22%。主要诊断错误集中在晶状体疾患这章,错误例数达1012份,占比93.79%。修正后MDC和DRGs减少,权重升高。结论住院病案首页数据质量直接影响DRGs分组结果与科室医疗技术服务能力水平的评价,了解白内障分型掌握分类规则才能进行正确病案分类,提高医师填写住院病案首页的重视度,增强HIS功能,保障数据的准确性。

Objective To analyze coding of the diagnosis and operation and its DRGs from the discharge patients of the Ophthalmology department of one comprehensive hospital, explore measurement to improve the coding accuracy of the front sheet. Methods A total of 2472 ophthalmic medical records discharged from January 1, 2017 to December 31, 2017 were collected, and the problem-oriented quality control was carried out on the home page of the hospitalized medical records. The errors were recorded, corrected by ICD and then re-entered into the group. Results There’s coding mistakes in 1079 cases, error rate is 43.65%. There is 24 cases influence DRGs result, which is 2.22% of these error cases. The majority mistakes of the first diagnosis is about the lens, which is 1012 cases, 93.79% of the error cases.Correction lead to less MDC and DRGs and the increasing of weight. Conclusion Coding quality affects DRGs and its weight directly. Clinicians should get more training about choosing the right first diagnosis, strengthen the structure of the HIS system, coding staff should learn more clinical knowledge and coding principle so that we could improve the accuracy of DRGs and the data quality of the first sheet of the patient record.