基于DRGs数据的恶性肿瘤病案主要诊断选择分析

Analysis of Main Diagnostic Choices of Malignant Tumor Based on DRGs Data

目的分析研究基于疾病诊断相关分组(diagnosis related groups,DRGs)数据的2 384例恶性肿瘤病案主要诊断选择中存在的问题,并据此提出解决方案。方法以卫计委制定的诊断选择标准作为指导,并与DRGs数据相结合,逐份核查相关恶性肿瘤病案,将病案号、科室、不同问题等数据记录在Excel表中,统计佛山市禅城区疾病预防控制中心2017年1月—2018年12月所记录的信息,将各科室的缺陷问题归类整理并进行统计分析。结果禅城区共需随访2017—2018年度本区户籍肿瘤病例4 686人,2019年3月31日,辖区社区卫生服务机构已完成对2017—2018年度本区户籍肿瘤病例的随访工作,共有效随访2 384人,有效率为50.87%。2 384份编目恶性肿瘤病案中,509份为主要诊断选择缺陷病案首页,缺陷率为21.35%。肿瘤专科的缺陷率显著低于较少收治恶性肿瘤患者的科室,其中缺陷率最高的三个科室依次为重症监护科、内分泌科、肾脏内科。结论病案首页中所记录的主要诊断编码要求相关编码人员务必要对病案进行仔细查阅,对编码原则加以熟练掌握,同时还应进一步加强自身相关临床专业知识,与医师之间保持良好的沟通。

Objective To analyze and study the problems in the main diagnosis of 2384 cases of malignant tumor based on(diagnosis related groups,DRGs)data,and put forward solutions.Methods Guided by the diagnostic selection criteria formulated by the health and Family Planning Commission and combined with DRGs data,the relevant malignant tumor medical records were checked one by one,and the medical record number,department and different problems were recorded in Excel table.The information recorded by the center for Disease Control and prevention of Chancheng District of Foshan City from January 2017 to December 2018 was counted,and the defects of each department were classified and sorted out analysis.Results A total of 4686 registered tumor cases were followed up in Chancheng District from 2017 to 2018.On March 31,2019,the community health service institutions of Chancheng District had completed the follow-up work on the registered tumor cases in this district in 2017-2018,with a total effective follow-up of 2384 people,with an effective rate of 50.87%.Among the 2384 catalogued malignant tumor medical records,509 were the first page of the main diagnosis selection defect medical records,and the defect rate was 21.35%.The defect rate of oncology department was significantly lower than that of the departments with less malignant tumor patients.The three departments with the highest defect rate were intensive care department,endocrine department and nephrology department.Conclusion The main diagnostic codes recorded in the front page of medical records require the relevant coding personnel to carefully consult the medical records and master the coding principles.At the same time,they should further strengthen their own clinical professional knowledge and maintain good communication with doctors.