妇科CHS-DRG入组异常病例住院病案首页填写缺陷

Analysis on the Coding Defects of Abnormal Cases Included in Gynecology Department Based on CHS-DRG

目的 分析某院妇科DRGs分组异常病案疾病编码过程中存在的问题,提出解决对策,持续改进编码数据质量。方法 从广西壮族自治区医保局反馈的3年CHS-DRGs分组,回顾性分析2017年1月1日-2019年12月31日3年妇科入组异常病例,随机抽取54份进行分析。结果 经过自查自纠发现54份入组异常病案临床医师主要诊断选择错误6例,主要诊断编码错误的有4例,主要手术编码错误的45例,主要诊断和主要手术编码同时错误的有2份。结论 DRGs入组异常病案是由编码能力以及临床医师病案书写问题造成。应开展病案首页的专项质控,督促临床医师规范填写病案首页,编码员正确编码,确保病案首页数据和DRGs分组数据的准确性。

Objectives This study aims to analyze the existing quality problems in the coding process of abnormal cases based on DRGs grouping in a hospital in order to put forward the countermeasures to continuously improve the quality of coding data. Methods DRGs grouping, from January 2016 to December 2019, was conducted by the DRGs platform of Guangxi Zhuang Autonomous Region Medical Insurance Bureau, and abnormal cases in gynecology department were retrospectively analyzed. 54 abnormal gynecological cases were randomly selected and analyzed. Results After self-examination and correction, this study found that the causes of 54 abnormal medical records were all related to the coders’ coding ability, the reading ability of medical records, and the doctors’ medical record writing level. Among those abnormal medical records, 6 cases had main diagnosis errors from clinicians, 4 cases had main diagnosis coding errors, 45 cases had main operation coding errors, and 2 cases had both main diagnosis and main operation coding errors. Conclusions The causes of abnormal medical records based on DRGs grouping are essentially the problem of coding ability and clinicians’ medical record writing level. It is necessary to strengthen the management of the medical record front pages, carry out special quality control of the medical record front pages, standardize the filling procedures on the medical record front pages for clinicians and coders, and ensure the accuracy of the front-page data and DRGS grouping data.