产科3430份住院病案首页编码质量对DRG分组的影响

Effect of Front Pages Coding Quality on DRG Grouping in 3430 Obstetric Inpatient Medical Records

目的通过分析某综合医院产科住院病案DRG分组情况及编码缺陷,提高入组准确性。方法收集2016年1月1日-2018年12月31日出院的产科住院病案共3430份,病案疾病分类人员以问题为导向进行病案编码质量监控,对存在缺陷的编码进行修正后重新入组汇总分析。结果产科住院病案首页主要诊断和主要手术错误628份,占病案总数的18.3%,问题集中在软产道裂伤诊断相关操作漏编码,占问题病案94.27%。修正后MDC和DRG组数减少,入MDCO组病例数增加21份,整体覆盖率由原来99.07%上升至99.68%。结论住院病案首页疾病编码缺陷对DRG入组产生不同程度的影响,导致分组结果与实际诊疗行为产生偏差。应提高医生病案首页填写的重视度,加强编码员ICD分类规则的学习,提升医院信息化水平,共同保障DRG入组的准确性。

Objectives To analyze DRG grouping and coding defects of obstetric inpatient medical records in a general hospital and put forward corresponding improvement measures.Methods A total of 3430 obstetric inpatient medical records were collected from January 1 st,2016 to December 31 st,2018.The quality of medical record coding was monitored by the disease classification staff based on the problem orientation,and the defective codes were corrected and then re-grouped for summary analysis.Results There were 628 cases of major diagnosis and surgical errors on the front pages of obstetric inpatient medical records,accounting for 18.3%of the total cases.The problems were mainly related to the missing coding of soft birth canal laceration diagnosis,accounting for 94.27%of the cases.After modification,the number of MDC and DRG groups decreased,and the number of cases in MDCO group increased by 21,and the overall coverage rate increased from 99.07%to 99.68%.Conclusions The defect of disease coding in the front pages of inpatient medical records had different effects on the inclusion of DRG,leading to deviation between grouping results and actual diagnosis and treatment behaviors.We should pay more attention to filling in the first page of medical records,strengthen the study of ICD classification rules by coders,improve the level of hospital informatization,and jointly guarantee the accuracy of DRG inclusion.