耳鼻喉科主要诊断与手术操作不一致对DRGs医疗服务绩效的影响

Influence of Inconsistencies between Main Diagnoses and Surgical Operations in Otolaryngology Department on the Medical Service Performance of DRGs

目的分析湖南省某三级甲等医院主要诊断与手术操作不一致的原因,并研究对DRGs相关医疗服务绩效的影响,为提高病案首页质量提供依据。方法提取电子病历系统中2019年1月1日-2019年12月31日耳鼻喉科3978份出院病案首页信息,运用CN-DRG分组器系统,在未入组情况中查找主要诊断与手术操作不一致的病例,核查病案质量,对比分析校正前后耳鼻喉科4个亚专科DRGs相关医疗服务绩效变化。结果共有114份病案因主要诊断与手术操作不一致导致未入组,主要原因有主要诊断填写不规范、主要手术操作填写不规范、编码错误、其他原因(分组器规则)等。矫正后耳鼻喉科入组病例数增加81例,CMI值增加0.0064,DRGs组数增加10组,总权重增加105.09。校正后入组率由97.13%提高到99.17%,不同亚专科呈现不同变化。结论主要诊断与手术操作不一致直接影响DRGs分组和相关医疗服务绩效评价,提高临床医师病案书写质量、加强编码员的专科知识能力和编码水平、搭建全流程质控模式有利于减少缺陷情况,能够有效提高病案首页质量。

Objectives To analyze the causes of the inconsistencies between the main diagnosis and surgical operation in a Three A and Tertiary Hospital in Hunan Province,study the impact on the performance of DRGs related medical services,and put forward basis for improving the quality of the front pages of medical records.Methods The front pages’information of 3978 discharged medical records in Department of Otolaryngology was extracted from the electronic medical record system from January 1 st,2019 to December 31 st,2019.The CN-DRG grouping system was used to find out the medical records whose main diagnosis was inconsistent with the operation in the cases not included in the group.The quality of the medical records was checked,and the changes of DRGs related medical service performance in four sub-specialties of Otorhinolaryngology before and after correction were analyzed.Results A total of 114 cases were not included in the group due to the inconsistency between the main diagnosis and operation.The main reasons were that the main diagnosis filling was not standardized,the main operation filling was not standardized,coding error,other reasons(grouping rules)and so on.After correction,the number of Otolaryngology cases increased by 81,CMI increased by 0.0064,DRGs group increased by 10 groups,and the total weight increased by 105.09.After correction,the enrollment rate increased from 97.13% to 99.17%,and different sub specialties showed different changes.Conclusions The inconsistencies between the main diagnosis and surgical operation directly affected the grouping of DRGs and the performance evaluation of related medical services.To effectively improve the quality of the front pages of medical records,we should improve the quality of medical record writing of clinicians,strengthen the professional knowledge and coding level of coders,build the whole process quality control mode to reduce defects.