基于CHS-DRG分组的某院2022年歧义病案分析

Analysis of QY medical records in a hospital in 2022 based on CHS-DRG grouping

目的汇总分析某院2022年歧义(QY)病案数据,找出入组异常原因,提出解决QY病案对策,规范病案首页及医保结算清单数据填报,提高疾病诊断相关分组(Diagnosis Related Groups,DRG)入组准确率。方法利用某市医疗保障局DRG综合管理应用平台,导出某院上传的2022年1月1日—12月31日的医保结算清单数据情况,筛选出某院2022年QY病例数据,基于住院病案首页填写规范以及CHS-DRG分组方案,回顾性分析QY病案填写缺陷,进行责任划分。结果某院2022年QY病案数233份,主要诊断选择错误病历数47份,其他诊断填写错误病历数6份,主要手术/操作选择错误病历数64份,主要操作多填病历数22份,DRG分组器缺陷导致歧义病历数66份,DRG分组器误判歧义病历数20份,本次住院同时治疗基础疾病8份。结论歧义病案发生的原因有ICD规则与医保结算清单填写规范存在差异,临床医生病历书写存在问题,编码员编码规则把握不准,合并基础疾病,DRG分组器固有缺陷。应通过加强医保结算清单填写规范学习,建立病案书写质量提升长效机制,持续开展编码继续教育,构建临床医师、编码员实时交流平台,定期与医保部门沟通,调整不合理分组方案等措施减少歧义病案发生。

Objective To collect and analyze the data of QY in 2022 in a hospital,find out the abnormal reasons for the enrollment,put forward the countermeasures to solve the QY,standardize the data filling in the front page of the medical record,and improve the accuracy of DRG enrollment.Methods Using the DRG comprehensive management application platform of a municipal medical security bureau,the data of the medical insurance settlement list uploaded by a hospital from January 1,2022 to December 31,2022 was derived,the data of QY cases in 2022 in a hospital were screened out,and based on the criterion of filling in the first page of medical records and the scheme of grouping CHS-DRG,the defects of filling in the medical records of QY were analyzed retrospectively,and the responsibility was divided.Results In 2022,there were 233 cases of QY in one hospital,47 cases of wrong selection of main diagnosis,6 cases of wrong filling in other diagnosis,64 cases of wrong selection of main operation,there were 22 cases of overfilling,66 cases of ambiguous medical records caused by defect of DRG,20 cases of ambiguous medical records misjudged by DRG,and 8 cases of underlying diseases were treated at the same time.Conclusion The causes of the ambiguous medical records are the differences between ICD rules and the norms of filling in the medical insurance settlement list,the problems in the writing of the medical records by clinical doctors,the inaccurate grasp of the coding rules by the coders,and the amalgamation of the underlying diseases,DRG packet inherent defects.We should strengthen standardized learning in the completion of Medicare checklists,establish a long-term mechanism to improve the quality of medical records,continue to develop coding Continuing education,and build a real-time communication platform for clinicians and coders,regular communication with the health insurance department,adjust the unreasonable grouping scheme and other to measures reduce the occurrence of ambiguous medical records.