基于DRG的低风险死亡住院病案首页分析与整改措施

Analysis and Rectification Measures on Homepages of Low Risk Death Medical Records Based on DRGs

目的 通过分析DRG 入组误入低风险死亡病例组的原因,提出具体整改措施,减少低风险死亡病例入组率。方法 对某院2019 年1 月1 日-2019 年12 月31 日22 例误入组为低风险的死亡病案进行住院病案首页填写分析,查找出具体原因。结果 因住院病案首页填写缺陷导致入组低风险死亡病例组的有13份,因分组器原因的9 份。结论 通过强化病历核心制度落实、实施住院病案首页数据质量考核办法、加强住院病案首页数据质量培训、建立死亡病历编码讨论制度和建设住院病案首页数据智能审核系统等措施,减少低风险死亡病例入组率。

Objective To analyze the causes of mistakenly entering the low-risk death group of DRGs, and to put forward specific rectification measures to reduce the enrollment rate of low-risk death cases of DRGs. Methods 22 cases of mistakenly entering the low-risk death group of DRG were filled in the homepage and analyzed to find out the specific causes from January 1, 2019 to December 31, 2019 in a hospital. Results There were 13 cases with low risk of death due to the defect of filling in the homepage of medical records, and 9 cases due to grouping device. Conclusion Through strengthening the implementation of the core system of medical records, implementing the home page data quality assessment method, strengthening the home page data quality training, establishing the death medical record discussion system and building the home page data intelligent audit system, the enrollment rate of low-risk death cases can be reduced.