基于DIP背景下某院2020年住院病案首页ICD编码缺陷分析

Analysis of ICD Coding Defects on the Front Page of Medical Records during 2020 based on DIP Background

目的 对广东省广州市某医院2020年出院患者住院病案首页进行随机抽查,核查疾病诊断和手术操作编码的准确性,分析编码错误原因及类型,为提高二级医院住院病案首页编码质量提供依据,有利于大数据病种分值付费(DIP)系统精细化管理。方法 采取分层等比例随机抽样法,从2020年1月1日到2020年12月31日每月随机抽取400份出院病案进行ICD编码核查,对编码错误情况进行归纳分析,对主要诊断或主要手术操作编码错误的病案进行DIP病种分组情况分析。结果 随机抽取的4800份住院病案中,疾病编码错误病案384份,手术编码错误病案138份。疾病编码缺陷率为8%,手术编码缺陷率为12%。其中肌肉骨骼系统、女性生殖系统和消化系统的手术编码错误发生率较高。主要诊断或主要手术操作编码错误导致DIP病种分组分值偏低。结论 二级医院住院病案首页编码工作仍存在不足,编码错误的常见原因如医师病案书写不完整、编码员编码规则掌握不准确及无仔细阅读病历习惯等,导致疾病诊断或手术编码错误,影响DIP病种分组和分值。

Objective To verify the accuracy of ICD codes on the front page in medical records of discharged patients in a Guangzhou hospital during 2020.To analyzed the cause and type of coding defects,providing evidence for improving coding quality in secondary hospital,so as to create delicacy management of The Big Data Diagnosis-Intervention Packet(DIP) payment system.Methods Using stratified equal proportion sampling method,400 discharged medical records were randomly selected every month from January 1,2020 to December 31,2020 for coding verification,and the coding errors were summarized and analyzed.The medical record with main diagnosis or surgical operation coding error were picked and analyzed the changes of DIP grouping between coding correct and incorrect condition.Results Among the 4800 medical records randomly selected,384 have disease coding mistakes and 138 have operation coding mistakes.The defect rate of disease coding was 8%,and that of operation coding was 12%.The incidence of coding errors in musculoskeletal system,female reproductive system and digestive system was higher.The coding error of main diagnosis or main surgical operation affects the DIP grouping and score.Conclusion For secondary hospital,there are still many deficiencies among coding quality in medical record.For example,coders lack of professional knowledge and the medical records are still not complete written by doctors,which lead to coding errors in disease diagnosis and surgical operation,affecting DIP grouping and score.