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乳腺肿瘤外科CHS-DRG入组现状及歧义病案原因分析 被引量:1

Analysis on the Current Situation of CHS-DRG in Breast Cancer Surgery and the Causes of Ambiguous Medical Records
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摘要 目的通过对某三级甲等肿瘤专科医院乳腺肿瘤外科CHS-DRG入组现状及歧义病案产生原因进行分析,提出整改措施,以期提高住院病案首页填报质量和DRG入组准确率。方法对某医院2021年11月1日至2022年3月31日于乳腺肿瘤外科出院且按DRG结算的2317份住院病案首页入组现状进行描述性分析。通过查阅原始病历和检查、检验结果及编码员集体讨论等分析歧义病案产生原因,通过帕累托图对歧义病案的原因类型进行分析。结果乳腺肿瘤外科CHS-DRG入组率为98.2%,入“乳房恶性肿瘤根治性切除术,不伴并发症或合并症(JA25)”和“乳房恶性肿瘤根治性切除术,伴并发症或合并症(JA23)”组的病历数共1028个,占比高达44.3%;共有歧义病案42份,歧义病案产生原因有DRG分组规则缺陷及住院病案首页主要诊断选择错误等。结论乳腺肿瘤外科住院病案首页入组率较高,但仍有少部分住院病案首页进入歧义组,歧义病案产生的主要原因是DRG分组规则缺陷,医院要积累歧义案例,及时向有关部门进行反馈,以期分组器得到优化,多措并举提高CHS-DRG入组率。 Objectives The paper aimed at analyzing the current situation of CHS-DRG enrollment and the causes of ambiguous medical records in breast cancer surgery of a Three A and Tertiary Cancer Hospital,and put forward corrective measures in order to improve the quality of the front page of inpatient medical records and the accuracy of DRG enrollment.Methods Descriptive analysis was used to show the current situation of the front page of 2317 inpatient medical records discharged from the breast cancer surgery department of a hospital from November 1st,2021 to March 31st,2022 and settled by DRG.The causes of ambiguous medical records were analyzed by referring to the original medical records,examination and test results,and coders'collective discussion.The cause types of ambiguous inpatient medical records were analyzed by Pareto Diagram.Results In this study,the enrollment rate of CHS-DRG in breast cancer surgery was 98.2%,1028 cases were enrolled in the"radical resection of breast cancer without complications or complications(JA25)"and"radical resection of breast cancer with complications or complications(JA23)"groups,accounting for 44.3%;There were 42 ambiguous medical records,and the causes of ambiguous medical records include the defects of DRG grouping rules and the main diagnosis selection errors on the front page of medical records.Conclusions The front page of breast cancer surgical medical records had a high enrollment rate,but a small number of the front page still entered the ambiguity group.The main reason for the ambiguity of medical records was the defect of DRG grouping rules.The hospital should accumulate ambiguity cases and provide feedback to the relevant departments in a timely manner in order to optimize the grouping device and take multiple measures to improve the CHS-DRG enrollment rate.
作者 高丽娜 王洪涛 王伟平 杨晓宇 李媛 车凡 王春梅 陈朦朦 Gao Lina;Wang Hongtao;Wang Weiping;Yang Xiaoyu;Li Yuan;Che Fan;Wang Chunmei;Chen Mengmeng(Tianjin Medical University Cancer Institute&Hospital,National Clinical Research Center for Cancer,Tianjin’s Clinical Research Center for Cancer,Key Laboratory of Breast Cancer Prevention and Therapy,Tianjin Medical University,Ministry of Education,Key Laboratory of Cancer Prevention and Therapy of Tianjin,Tianjin 300060,China;不详)
出处 《中国病案》 2023年第10期38-40,共3页 Chinese Medical Record
基金 天津医科大学医院管理创新研究项目(2021YG07) 天津市医学重点学科(专科)建设项目(TJYXZDXK-009A)。
关键词 乳腺肿瘤 CHS-DRG 歧义病案 Breast tumor CHS-DRG Ambiguous medical records
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