DRG应用中疼痛科歧义病案的探讨

Exploration on Ambiguous Medical Records in Pain Department during DRG Application

目的分析疾病诊断相关分组(DRG)应用中的疼痛科歧义病案。方法针对疼痛科2021年1-12月DRG结算系统的112份病案进行调查,对其中10份歧义病案相关情况进行总结。结果分析疼痛科上传的112份出院结算病案,以分组器分组后,入组病案99份,入组率88.39%。疼痛科手术/操作病案72份,歧义病案10份,歧义发生率13.89%。10份歧义病案中,主要诊断选择错误1份(10.00%),主要手术选择错误1份(10.00%),编码错误1份(10.00%),转科2份(20.00%),住院时间1份(10.00%),分组规则因素4份(40.00%)。结论DRG应用中,疼痛科歧义病案出现的主要原因为分组规则因素,可通过强化专业培训与规范信息填报等方式予以改进。

Objective To analyze ambiguous medical records in pain department during application of disease diagnosis related grouping(DRG).Methods The paper carrion on survey on 112 medical records grouped in DRG settlement system in pain department from January to December 2021 and summarized10 ambiguous medical records.Results Based on analysis of 112 discharge settlement medical records uploaded by the pain department,after grouping with a grouping device,99 medical records were enrolled,with an enrollment rate of 88.39%.There were 72 surgical/operational medical records and 10 ambiguous medical records in pain department,with an incidence rate of 13.89%.Among the 10 ambiguous medical records,1 was diagnosed incorrectly(10.00%),1 was diagnosed incorrectly(10.00%),1 was coded incorrectly(10.00%),2 were transferred to another department(20.00%),1 was hospitalized(10.00%)and 4 were grouped based on rule factors(40.00%).Conclusion During application of DRG,main reason for ambiguous medical records in pain department is grouping rule factor,which can be improved by strengthening professional training and standardizing information reporting.