歧义病案产生的影响因素分析

Analysis on the Influencing Factors of Ambiguous Medical Records

目的基于疾病诊断相关分组,分析某DRG试点医院歧义病案产生的影响因素及原因,为减少歧义病案和提高病案质量提供思路。方法回顾性分析2021年11月1日-2022年4月30日哈尔滨市某DRG试点医院21318份出院医保结算病案,利用CHS-DRG1.1版信息平台,筛查出338份歧义病案。采用t检验、χ2检验及二元Logistic回归分析统计学方法分析歧义病案的影响因素及原因。结果歧义病案占研究病案总数的1.59%。t检验和χ2检验显示非歧义病案组与歧义病案组在住院天数、是否转科、出院科别及核心疾病诊断相关分组之间差异有统计学意义,P<0.05;二元Logistic回归分析得出,住院天数、是否转科及出院科别是歧义病案的影响因素。结论住院天数、是否转科、出院科别与歧义病案的产生密切相关,是其影响因素。可以通过缩短平均住院日、减少非必要转科、针对性加强临床医生和编码员的专业知识,定期开展病案首页编码知识相关培训,进而减少歧义病案,提高病案质量。

Objectives Based on diagnosis related groups,this paper analyzed the influencing factors and causes of ambiguous medical records in a DRG pilot hospital,and provided ideas for reducing ambiguous medical records and improving the quality of medical records.Methods A retrospective investigation was conducted on 21318 medical records of medical insurance settlement discharged from a DRG pilot hospital in Harbin from November 1st,2021 to April 30th,2022.338 ambiguous medical records were screened by using CHS-DRG1.1 information platform.t-test andχ2 test and binary logistic regression analysis were used to analyze the influencing factors and causes of ambiguous medical records.Results Ambiguous medical records accounted for 1.59%of the total number of medical records studied.t-test andχ2 test showed that there were significant differences between the non-ambiguous medical record group and the ambiguous medical record group in the number of days in hospital,whether to transfer to another department,discharge department and adjacent diagnosis related groups(ADRG)(P<0.05);Binary logistic regression analysis showed that the number of days in hospital,whether to transfer to another department and the department of discharge were the influencing factors of ambiguous medical records(P<0.05).Conclusions The number of days in hospital,whether to transfer to another department,and the department of discharge are closely related to the occurrence of ambiguous medical records.By shortening the average length of stay,reducing unnecessary transfer,strengthening the professional knowledge of clinicians and coders,and carrying out regular training on the coding knowledge of the front page of medical records,ambiguous medical records could be reduced and the quality of medical records could be improved.